HIMSS Immunization Integration Program CDC Test Plan v7.3

This test plan is to be used for the testing of the CDC EHR Immunization Related Requirements developed under Contract-No: 200-2014-60994 . All test cases are required to be executed. The test plan includes both functional and interoperability tests including Vaccine Update Notifications (HL7 V2.5.1 VXU/Z22) and Query and Response (Evaluated History and Forecast Group Z44/Z42). This version is updated for use in the 2018 test cycle. It is aligned with ONC 2015 Certification Criteria for § 170.315(f)(1) Transmission to Immunization Registries. This test plan is approved by ONC to demonstrate conformance to this criteria.

Test Story

Description

Comments

Pre-condition

Post-Condition

Test Objectives

Evaluation Criteria

Notes

1. Initial Data Load

The initial data load will consist of the vendor entering data during live interactive testing for 4 patients with various scenarios. The data entry will include demographic data, Immunization histories and specific conditions for each patient. The initial data load will also populate the inventory used in the use case.

Test Story

Description

Comments

Pre-condition

Post-Condition

Test Objectives

Evaluation Criteria

Notes

1.1. Juana Mariana Vazquez Initial Data Load

Demonstrates the ability to record pediatric demographic data, historical vaccinations, and clinical conditions for a school-aged child Juana Mariana Vazquez. There are no transactions associated with this test case.

Test Story

Description
The practice site for the scenario is Shoreline Pediatrics. The EHR vendor loads demographic data and clinical history for Juana Mariana Vazquez. The data includes immunizations provided by the practice. The vendor also enters: -Two vaccines administered at other sites 1. an influenza vaccine given at a local pharmacy 2. an inactivated polio vaccine given elsewhere and not reported to the registry - the history includes an adverse reaction (febrile seizure) 8 hours after the vaccine was administered - Adverse reaction to inactivated polio vaccine (febrile seizure) and the date and source of information NOTE: the historical vaccines will be imported during the Registry query (e.g. from another practice)

Description

The practice site for the scenario is Shoreline Pediatrics. The EHR vendor loads demographic data and clinical history for Juana Mariana Vazquez. The data includes immunizations provided by the practice.

The vendor also enters:

-Two vaccines administered at other sites

1. an influenza vaccine given at a local pharmacy

2. an inactivated polio vaccine given elsewhere and not reported to the registry - the history includes an adverse reaction (febrile seizure) 8 hours after the vaccine was administered

- Adverse reaction to inactivated polio vaccine (febrile seizure) and the date and source of information

NOTE: the historical vaccines will be imported during the Registry query (e.g. from another practice)

Comments
Set-up step evaluating EMR functions for capturing and storing patient pediatric demographic data, historical immunizations, and clinical conditions. There is no transaction associated with this test step.

Pre-condition
No PreCondition

Post-Condition
The EMR has recorded all of the pediatric demographic data, historical immunizations, and clinical conditions in the record created for Juana Mariana Vazquez using the test data provided.

Test Objectives
Register New Patients: The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information. For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother's maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient's information to external systems such as an immunization registry. Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details. Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry. Supporting data for: Compare Public Health Immunization Registry (IIS) Immunization History to EHR Immunization History: The public health immunization registry has returned the requested immunization history for a patient. The EHR is able to display the immunization history received from the registry as well as the immunization history already present in the EHR so that a user can compare them. The EHR provides a way for the provider to view both histories, determine what is different (if anything), and update the existing EHR immunization history with new information from the public health registry if he or she chooses to do so. The system must store the new information as structured data as part of the patient's local immunization history and include the time of the update and the source of the new information. Identify Adverse Event: The EHR or other clinical software system enables capture of structured data regarding adverse events.

Test Objectives

Register New Patients: The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information. For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother's maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient's information to external systems such as an immunization registry.

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry.

Supporting data for:

Compare Public Health Immunization Registry (IIS) Immunization History to EHR Immunization History: The public health immunization registry has returned the requested immunization history for a patient. The EHR is able to display the immunization history received from the registry as well as the immunization history already present in the EHR so that a user can compare them. The EHR provides a way for the provider to view both histories, determine what is different (if anything), and update the existing EHR immunization history with new information from the public health registry if he or she chooses to do so. The system must store the new information as structured data as part of the patient's local immunization history and include the time of the update and the source of the new information.

Identify Adverse Event: The EHR or other clinical software system enables capture of structured data regarding adverse events.

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
No Note

1.1.1. Enter Initial Demographic Data for New Patient Juana Mariana Vazquez

Test Step Type: SUT_MANUAL
Juana Mariana Vazquez is entered as a patient in the EMR, including all pediatric demographic information.

Test Story

Description
The EHR vendor loads demographic data for Juana Mariana Vazquez.

Comments
Set-up step evaluating EMR functions for capturing and storing patient pediatric demographic data. There is no transaction associated with this test step.

Pre-condition
No PreCondition

Post-Condition
The EMR has recorded all of the pediatric demographic in the record created for Juana Mariana Vazquez.

Test Objectives
*Register New Patients:* The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information. For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother's maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient's information to external systems such as an immunization registry.

Test Objectives

Register New Patients: The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information. For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother's maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient's information to external systems such as an immunization registry.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all demographic data provided, and in particular (Mother's maiden name, multiple birth, birth order), with all required attributes indicated by [Y], The code values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the specified coded value when the attribute is conveyed in later transaction messages.

For systems that document VFC eligibility at the patient level: VFC Eligible

Patient ID (previously listed as "Medicaid Number")	Vendor supplied	Y
Patient ID: Assigning Authority ID (i.e., owning source)/Facility Name	Shoreline Pediatrics	Y
Patient ID: Type (e.g., medical record number, IIS ID)	Vendor supplied	Y
Patient Name: First	Juana	Y
Patient Name: Middle	Mariana	Y
Patient Name: Last	Vazquez	Y
Patient Date of Birth	11/01/2013	Y
Birth Time	11:05	N
Patient Gender (Administrative Sex)	F	Y
Patient Multiple Birth Indicator	No	Y
Patient Birth Order	NA	C
Responsible Person Name: First	Joanna	Y
Responsible Person Name: Middle	Merida	Y
Responsible Person Name: Last	Vazquez	Y
Responsible Person Name: Relationship to Patient	Grandmother	Y
Mother's Name: First	Maria	Y
Mother's Name: Middle	Merida	Y
Mother's Name: Last	Vazquez	Y
Mother's Name: Maiden Last	Acosta	Y
Patient Address: Street	4345 Standish Way	Y
Patient Address: City	Stamford	Y
Patient Address: State	CT	Y
Patient Address: Country	USA	Y
Patient Address: Zipcode	06903	Y
Patient Address: County of Residence	Fairfield	N
Race	White	Y
Ethnicity	Hispanic or Latino	Y
Birthing Facility Name (Birth Delivery Location Address BDL)	Shoreline Hospital 325 Shorline Drive, Stamford Connecticut 06901	[Y - birthing facility name, not address]
Patient Birth State	CT	Y
Patient Primary Language	English	Y
Patient Telephone Number	(203) 555-1212	Y
Patient Telephone Number Type (e.g., home, cell)	cell	Y
Patient E-mail Address	jmg@gmail.com	N
Publicity Code	Reminder/recall - any method (02 HL70215)	Y
Protection Indicator	N	Y
Protection Indicator Effective Date	NA	N
Immunization Registry Status	NA	N
Preferred Contact Method	Phone	Y

Notes
Publicity Code is included in order to support documentation of communication method for the TestCaseGroup:Cohort Report. If the EMR does not support this attribute, the result for this step may indicate pass, but the lack of support should be documented as a notable exception. The date/time of birth for the twins includes birth time. This aids in distinguishing the birth order for multiple births. Since this patient is not a multiple birth, the vendor can pass with notable exception if the birth date/time does not include precision of birth time. The notable exception should document the lack of support for birth time. While the PID indicates that it is Vendor Supplied, the ID returned from the registry query is: 123456^^^MYEHR^MR~987633^^^MYIIS^SR. The IIS will not know the PID of the local system, and there is no context-based validation checking for the PID.

Notes

Publicity Code is included in order to support documentation of communication method for the TestCaseGroup:Cohort Report. If the EMR does not support this attribute, the result for this step may indicate pass, but the lack of support should be documented as a notable exception.

The date/time of birth for the twins includes birth time. This aids in distinguishing the birth order for multiple births. Since this patient is not a multiple birth, the vendor can pass with notable exception if the birth date/time does not include precision of birth time. The notable exception should document the lack of support for birth time.

While the PID indicates that it is Vendor Supplied, the ID returned from the registry query is: 123456^^^MYEHR^MR~987633^^^MYIIS^SR. The IIS will not know the PID of the local system, and there is no context-based validation checking for the PID.

1.1.2. Enter Initial Immunization Data for Juana Mariana Vazquez: Immunizations from practice

Test Step Type: SUT_MANUAL
Patient History from the local practice is entered into the EMR.

Test Story

Description
The EHR vendor loads immunization history data from the local practice for Juana Mariana Vazquez. This includes an MMR dose that was given too early. This MMR dose serves to seed checking for dose given too early in TestCaseGroup: Juana Mariana Vazquez Visit, TestCase: Query the Registry for Juana Mariana Vazquez, TestStep: Mark first MMR Dose as Invalid.

Comments
No Comments

Pre-condition
The EMR has recorded all of the pediatric demographic data in the record created for Juana Mariana Vazquez.

Post-Condition
The immunization history known to the local practice is loaded into the record created for Juana Mariana Vazquez.

Test Objectives
Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details. Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry. Supporting data for: *Compare Public Health Immunization Registry (IIS) Immunization History to EHR Immunization History:* The public health immunization registry has returned the requested immunization history for a patient. The EHR is able to display the immunization history received from the registry as well as the immunization history already present in the EHR so that a user can compare them. The EHR provides a way for the provider to view both histories, determine what is different (if anything), and update the existing EHR immunization history with new information from the public health registry if he or she chooses to do so. The system must store the new information as structured data as part of the patient's local immunization history and include the time of the update and the source of the new information. Receive Dose Not Indicated Alert for Single Vaccine Order: The EHR or other clinical software system notifies the provider in instances when there are single or combination vaccine orders that are inconsistent with the expected timing intervals included in the vaccine forecast. Inconsistencies include suggestion of different date(s) for ordering the vaccine(s) or indication the vaccine(s) is/are no longer required.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry.

Supporting data for:

Compare Public Health Immunization Registry (IIS) Immunization History to EHR Immunization History: The public health immunization registry has returned the requested immunization history for a patient. The EHR is able to display the immunization history received from the registry as well as the immunization history already present in the EHR so that a user can compare them. The EHR provides a way for the provider to view both histories, determine what is different (if anything), and update the existing EHR immunization history with new information from the public health registry if he or she chooses to do so. The system must store the new information as structured data as part of the patient's local immunization history and include the time of the update and the source of the new information.

Receive Dose Not Indicated Alert for Single Vaccine Order: The EHR or other clinical software system notifies the provider in instances when there are single or combination vaccine orders that are inconsistent with the expected timing intervals included in the vaccine forecast. Inconsistencies include suggestion of different date(s) for ordering the vaccine(s) or indication the vaccine(s) is/are no longer required.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:

Vaccine from Practice HepB
Entered BY	Sandra Molina	Y
Ordering Provider	Frank Smith	N
Entering Organization	Shoreline Pediatrics	Y
Administration Notes (Vaccine Event information source)	New immunization record (NIP001 00)	Y
Date/Time of Start of Administration	12/20/2014	Y
Vaccine Administered	hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08, NDC 58160-0820-01)	Y
Administered Amount (of Vaccine)	0.5	Y
Administered Units (of Measure)	mL	Y
Administering Provider	Sandra Molina	N
Administered-at Location	400 Shoreline Drive, Stamford Connecticut 06901	N
Lot Number	6352FK1	Y
Substance Expiration Date	12/31/2014	Y
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA (MVX SKB)	Y
Completion Status	Completed (CP)	Y
Route of Administration	Intramuscular (NCIT C28161, HL70162: IM)	Y
Administration Site	Left Thigh (HL70163 LT)	Y

Vaccine from Practice MMR
a. Entered BY	J. Martinez	Y
b. Ordering Provider	Frank Smith	N
c. Entering Organization	Shoreline Pediatrics	Y
Vaccine Event information source	New immunization record (NIP001 00)	Y
Value/Text for Vaccine Type	Measles, mumps, rubella virus vaccine (CVX 03, NDC 0006-4681-00)	Y
Date/Time of Start of Administration	08/22/2014	Y
Vaccine Administered	Measles, mumps, rubella virus vaccine (CVX 03, NDC 0006-4681-00)	Y
Administered Amount (of Vaccine)	0.5	Y
Administered Units (of Measure)	mL	Y
Administering Provider	Sandra Molina	N
Administered-at Location	400 Shoreline Drive, Stamford Connecticut 06901	N
Lot Number	0853CC	Y
Substance Expiration Date	12/15/2015	Y
Substance Manufacturer Name	Merck Sharp & Dohme Corp (MVX MSD)	Y
Completion Status	Completed (CP)	Y
Route of Administration	Intramuscular (NCIT C28161 HL70162 IM)	Y
Administration Site	Right Thigh (HL70163 RT)	Y

Notes
The MMR dose serves to seed checking for dose given too early in TestCaseGroup: Juana Mariana Vazquez Visit, TestCase: Query the Registry for Juana Mariana Vazquez, TestStep: Mark first MMR Dose as Invalid. The EMR does not need to specify a 'new immunization', as long as there is a way to indicate that it is a new immunization within the EMR, this is acceptable (e.g. the default interpretation of the data entry is that it is a new immunization and not historical).

Notes

The MMR dose serves to seed checking for dose given too early in TestCaseGroup: Juana Mariana Vazquez Visit, TestCase: Query the Registry for Juana Mariana Vazquez, TestStep: Mark first MMR Dose as Invalid.

The EMR does not need to specify a 'new immunization', as long as there is a way to indicate that it is a new immunization within the EMR, this is acceptable (e.g. the default interpretation of the data entry is that it is a new immunization and not historical).

1.1.3. Enter Initial Immunization Data for Juana Mariana Vazquez from Another Practice

Test Step Type: SUT_MANUAL
Patient History from another practice is entered into the EMR.

Test Story

Description
The EHR vendor loads immunization history data from another practice into the record for Juana Mariana Vazquez.

Comments
No Comments

Pre-condition
The EMR has recorded all of the pediatric demographic data in the record created for Juana Mariana Vazquez.

Post-Condition
The immunization history from another practice is loaded into the record created for Juana Mariana Vazquez.

Test Objectives
Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details. Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry. Supporting data for: *Compare Public Health Immunization Registry (IIS) Immunization History to EHR Immunization History:* The public health immunization registry has returned the requested immunization history for a patient. The EHR is able to display the immunization history received from the registry as well as the immunization history already present in the EHR so that a user can compare them. The EHR provides a way for the provider to view both histories, determine what is different (if anything), and update the existing EHR immunization history with new information from the public health registry if he or she chooses to do so. The system must store the new information as structured data as part of the patient's local immunization history and include the time of the update and the source of the new information.

Test Objectives

Supporting data for:

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization history data from another practice as provided, with all required attributes indicated by [Y]:

Historical Vaccine from Another Practice - DTaP

Entering Organization

Shoreline Pediatrics

Vaccine Event information source (Administration Notes)

Historical information - from other provider (NIP001 02)

Value/Text for Vaccine Type

DTaP

Date/Time of Start of Administration

11/20/2017

Vaccine Administered

diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) (NDC 49281-0286-01)

Administered Amount (of Vaccine)

0.5

Administered Units (of Measure)

Administering Provider

Linda Casera

Administered-at Location

4253 Standish Way, Stamford Connecticut 06903

Lot Number

D643QS8243

Substance Expiration Date

12/1/2017

Substance Manufacturer Name

Sanofi Pasteur Inc (MVX PMC)

Completion Status

Completed (CP)

Route of Administration

Intramuscular (NCIT C28161, HL70162 IM)

Administration Site

Left Deltoid (HL70163 LD)

Historical Vaccine from Another Practice - Polio

Entering Organization

Shoreline Pediatrics

Vaccine Event information source

Historical information - from other provider (NIP001 02)

Value/Text for Vaccine Type

poliovirus vaccine, inactivated (CVX 10)

Date/Time of Start of Administration

2/21/2015

Vaccine Administered

poliovirus vaccine, inactivated (CVX 10)

Administered Amount (of Vaccine)

0.5

Administered Units (of Measure)

Administering Provider

Linda Casera

Administered-at Location

4253 Standish Way, Stamford Connecticut 06903

Lot Number

D335PV9644

Substance Expiration Date

4/22/2015

Substance Manufacturer Name

Sanofi Pasteur Inc (MVX PMC)

Completion Status

Completed (CP)

Route of Administration

Intramuscular (NCIT C28161, HL70162 SC)

Administration Site

Left Deltoid (HL70163 LD)

Reaction

Adverse Reaction of (VXC12^fever of >40.5C (105F) within 48 hours of dose^CDCPHINVS)

Notes
No Note

1.1.4. Enter Initial Immunization Data for Juana Mariana Vazquez Reported by Parent

Test Step Type: SUT_MANUAL
Patient History from a pharmacy as reported by the parent is entered into the EMR.

Test Story

Description
The provider enters immunization data from a pharmacy as reported by the parent for Juana Mariana Vazquez.

Description

The provider enters immunization data from a pharmacy as reported by the parent for Juana Mariana Vazquez.

Comments
No Comments

Pre-condition
The EMR has recorded all of the pediatric demographic data in the record created for Juana Mariana Vazquez.

Post-Condition
The immunization history from the pharmacy as reported by the parent is loaded into the record created for Juana Mariana Vazquez.

Test Objectives

Supporting data for:

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization history data from the pharmacy as provided by the parent with all required attributes indicated by [Y]:

Historical Vaccine from Pharmacy Reported by Parent
Entered BY	Sandra Molina	Y
Ordering Provider	Gina Ricci	N
Entering Organization	Shoreline Pediatrics	Y
Vaccine Event information source (Administration Notes)	Historical information - from parent's written record (NIP001 03)	Y
Value/Text for Vaccine Type	Influenza vaccine	Y
Date/Time of Start of Administration	10/15/2017	Y
Vaccine Administered	influenza, seasonal, injectable, preservative Free (CVX 140) FLUARIX (NDC 58160-0883-41))	Y
Administered Amount (of Vaccine)	0.5	Y
Administered Units (of Measure)	mL	Y
Administering Provider	Gina Ricci	N
Administered-at Location	Oceanview Pharmacy, 15 Post Road, Stamford Connecticut 06901	Y
Lot Number	8L4B3423	Y
Substance Expiration Date	12/30/2017	Y
Substance Manufacturer Name	GlaxoSmithKline (MVX SKB)	Y
Completion Status	Completed (CP)	Y
Route of Administration	Intramuscular (NCIT C28161, HL70162 IM)	Y
Administration Site	Left Deltoid (HL70163 LD)	Y

Notes
No Note

1.2. Juan Marcel Marina Initial Data Load

Demonstrates the ability to record pediatric demographic data, historical vaccinations, and clinical conditions for 1 1/2-year old Juan Marcel Marina. There are no transactions associated with this test case.

Test Story

Description

The practice site for the scenario is Shoreline Pediatrics. The EHR vendor loads demographic data and clinical history for Juan Marcel Marina. The data includes a clinical history of varicella, and serological evidence of Hepatitis A immunity.

Comments
Set-up step evaluating EMR functions for capturing and storing patient pediatric demographic data, historical immunizations, and clinical conditions. There is no transaction associated with this test step.

Pre-condition
No PreCondition

Post-Condition
The EMR has recorded all of the pediatric demographic data, historical immunizations, and clinical conditions in the record created for Juan Marcel Marina using the test data provided.

Test Objectives

Supporting data for:

Modify Antigen Recommendations Based on Active Diagnoses: The system notifies the provider of any conflicts between recommended vaccines in the updated forecast and the patient's current or historical diagnoses.

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
No Note

1.2.1. Enter Initial Demographic Data for New Patient Juan Marcel Marina

Test Step Type: SUT_MANUAL
Juan Marcel Marina is entered as a patient in the EMR, including all pediatric demographic information.

Test Story

Description
The EHR vendor loads demographic data for Juan Marcel Marina.

Comments
Set-up step evaluating EMR functions for capturing and storing patient pediatric demographic data. There is no transaction associated with this test step.

Pre-condition
No PreCondition

Post-Condition
The EMR has recorded all of the pediatric demographic in the record created for Juan Marcel Marina.

Test Objectives

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all demographic data provided, and in particular (Mother's maiden name, multiple birth, birth order), with all required attributes indicated by [Y]. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:

For systems that document VFC eligibility at the patient level: Not VFC Eligible

Patient ID (previously listed as "Medicaid Number")	Vendor supplied	Y
Patient ID: Assigning Authority ID (i.e., owning source)/Facility Name	Shoreline Pediatrics	Y
Patient ID: Type (e.g., medical record number, IIS ID)	Vendor supplied	Y
Patient Name: First	Juan	Y
Patient Name: Middle	Marcel	Y
Patient Name: Last	Marina	Y
Patient Date of Birth	03/04/2017	Y
Birth Time	11am	N
Patient Gender (Administrative Sex)	M	Y
Patient Multiple Birth Indicator	No	Y
Patient Birth Order	NA	C
Responsible Person Name: First	Manuel	Y
Responsible Person Name: Middle	Marcel	Y
Responsible Person Name: Last	Marina	Y
Responsible Person Name: Relationship to Patient	Father	Y
Mother's Name: First	Anita	Y
Mother's Name: Middle	Francesca	Y
Mother's Name: Last	Marina	Y
Mother's Name: Maiden Last	Morales	Y
Patient Address: Street	4623 Standish Way	Y
Patient Address: City	Stamford	Y
Patient Address: State	CT	Y
Patient Address: Country	USA	Y
Patient Address: Zipcode	06903	Y
Patient Address: County of Residence	Fairfield	N
Race	White	Y
Ethnicity	Hispanic or Latino	Y
Birthing Facility Name (Birth Delivery Location Address BDL)	Shoreline Hospital 325 Shoreline Drive, Stamford Connecticut 06901	[Y - birthing facility name, not address]
Patient Birth State	CT	Y
Patient Primary Language	English	Y
Patient Telephone Number	(203) 555-1213	Y
Patient Telephone Number Type (e.g., home, cell)	cell	Y
Patient E-mail Address	None	N
Publicity Code	Reminder/recall - no calls (03 HL70215)	Y
Protection Indicator	No	Y
Protection Indicator Effective Date		N
Immunization Registry Status		N
Preferred Contact Method	Text	Y

Notes

1.2.2. Enter Clinical History for Juan Marcel Marina

Test Step Type: SUT_MANUAL
The EHR captures structured data regarding varicella disorder and Hepatitis A Immunity identified by serologic results as part of the clinical history.

Test Story

Description

The clinical history of Chicken Pox (Varicella) is documented in the record created for Juan Marcel Marina.

The lab tests show serologic immunity to Hep A and a finding is added indicating Hepatitis A Immune

Comments
No Comments

Pre-condition
The EMR has recorded all of the pediatric demographic in the record created for Juan Marcel Marina.

Post-Condition

The clinical history of the Varicella is documented in the record created for Juan Marcel Marina.

The serologic immunity (Hepatitis A virus IgG+IgM Ab [Presence] in Serum) - result positive and a finding of Hepatitis A Immune is documented in the record for Juan Marcel Marina.

Test Objectives

Supporting data for:

In this case, the vaccine is not recommended due to the history of the vaccine preventable condition (Varicella).

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all clinical history data provided with all required attributes indicated by [Y]. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:

Serologic Evidence of Immunity to Hepatitis A is documented in the record:

Lab Result and Finding (1/15/2018):

LOINC 51913-2 Hepatitis A virus IgG+IgM Ab [Presence] in Serum - result positive

Finding of Hepatitis A Immunity is recorded (SNOMED 278971009 Hepatitis A Immune (finding))

History of Varicella (reason for vaccine forecast to not indicate varicella vaccine due)
Problem (3/16/2018)	Varicella (disorder) SNOMED-CT 38907003); Varicella without complication - (ICD-10-CM B01.9) Coded Value expected using SNOMED-CT or ICD-10-CM	Y	Coded value expected using SNOMED-CT or ICD

Notes
No Note

1.3. Juana Mariela Gonzales Initial Data Load

Demonstrates the ability to record pediatric demographic data, historical vaccinations, and clinical conditions for infant twin Juana Mariela Gonzales. There are no transactions associated with this test case.

Test Story

Description
The practice site for the scenario is Shoreline Pediatrics. The EHR vendor loads demographic data and clinical history for twin Juana Mariela Gonzales.

Comments
Set-up step evaluating EMR functions for capturing and storing patient pediatric demographic data, historical immunizations, and clinical conditions. There is no transaction associated with this test step.

Pre-condition
No PreCondition

Post-Condition
The EMR has recorded all of the pediatric demographic data, historical immunizations, and clinical conditions in the record created for Juana Mariela Gonzales using the test data provided.

Test Objectives

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
No Note

1.3.1. Enter Initial Demographic Data for Juana Mariela Gonzales

Test Step Type: SUT_MANUAL
Juana Mariela Gonzales, infant twin, is entered as a new patient in the EMR, including all pediatric demographic information.

Test Story

Description
The EHR vendor loads demographic data for Juana Mariela Gonzales.

Comments
Set-up step evaluating EMR functions for capturing and storing patient pediatric demographic data. There is no transaction associated with this test step.

Pre-condition
No PreCondition

Post-Condition
The EMR has recorded all of the pediatric demographic data in the record created for Juana Mariela Gonzales.

Test Objectives

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all demographic data provided, and in particular (Mother's maiden name, multiple birth, birth order), with all required attributes indicated by [Y]. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:

For systems that document VFC eligibility at the patient level: not VFC Eligible

Patient ID (previously listed as "Medicaid Number")	Vendor supplied	Y
Patient ID: Assigning Authority ID (i.e., owning source)/Facility Name	Shoreline Pediatrics	Y
Patient ID: Type (e.g., medical record number, IIS ID)	Vendor supplied	Y
Patient Name: First	Juana	Y
Patient Name: Middle	Mariela	Y
Patient Name: Last	Gonzales	Y
Patient Date of Birth	10/01/2018	Y
Birth Time	11am	N
Patient Gender (Administrative Sex)	F	Y
Patient Multiple Birth Indicator	Yes	Y
Patient Birth Order	1	Y
Responsible Person Name: First	Joanna	Y
Responsible Person Name: Middle	Elena	Y
Responsible Person Name: Last	Gonzales	Y
Responsible Person Name: Maiden Last	Morales	N
Relationship to Patient	Mother	Y
Mother's Name: First	Joanna	Y
Mother's Name: Middle	Elena	Y
Mother's Name: Last	Gonzales	Y
Mother's Name: Maiden Last	Morales	Y
Patient Address: Street	3321 Standish Way	Y
Patient Address: City	Stamford	Y
Patient Address: State	CT	Y
Patient Address: Country	USA	Y
Patient Address: Zipcode	06903	Y
Patient Address: County of Residence	Fairfield	N
Race	White	Y
Ethnicity	Hispanic or Latino	Y
Birthing Facility Name (Birth Delivery Location Address BDL)	Stamford Regional Hospital 15 Atlantic Avenue, Stamford Connecticut 06903	[Y - birthing facility name, not address]
Patient Birth State	CT	Y
Patient Primary Language	English	Y
Patient Telephone Number	(203) 555-1214	Y
Patient Telephone Number Type (e.g., home, cell)	cell	Y
Patient E-mail Address	none	N
Publicity Code	Reminder/recall - no calls (03 HL70215)	Y
Protection Indicator	N	N
Protection Indicator Effective Date	NA	N
Immunization Registry Status	NA	N
Preferred Contact Method	Text	Y

Notes

The date/time of birth for the twins includes birth time. This aids in distinguishing the birth order of the twins, but as long as birth order is supplied, the vendor can pass with notable exception if the birth date/time does not include precision of birth time. The notable exception should document the lack of support for birth time.

1.4. Juana Maria Gonzales Initial Data Load

Demonstrates the ability to record pediatric demographic data, historical vaccinations, and clinical conditions for infant twin Juana Maria Gonzales. There are no transactions associated with this test case.

Test Story

Description
The practice site for the scenario is Shoreline Pediatrics. The EHR vendor loads demographic data and clinical history for twin Juana Maria Gonzales.

Comments
Set-up step evaluating EMR functions for capturing and storing patient pediatric demographic data, historical immunizations, and clinical conditions. There is no transaction associated with this test step.

Pre-condition
No PreCondition

Post-Condition
The EMR has recorded all of the pediatric demographic data, historical immunizations, and clinical conditions in the record created for Juana Maria Gonzales using the test data provided.

Test Objectives

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
No Note

1.4.1. Enter Initial Demographic Data for Juana Maria Gonzales

Test Step Type: SUT_MANUAL
Juana Maria Gonzales, infant twin, is entered as a new patient in the EMR, including all pediatric demographic information.

Test Story

Description
The EHR vendor loads demographic data for Juana Maria Gonzales.

Comments
Set-up step evaluating EMR functions for capturing and storing patient pediatric demographic data. There is no transaction associated with this test step.

Pre-condition
No PreCondition

Post-Condition
The EMR has recorded all of the pediatric demographic data in the record created for Juana Maria Gonzales.

Test Objectives

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all demographic data provided, and in particular (Mother's maiden name, multiple birth, birth order), with all required attributes indicated by [Y]. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:

For systems that document VFC eligibility at the patient level: Not VFC Eligible

Patient ID (previously listed as "Medicaid Number")	Vendor supplied	Y
Patient ID: Assigning Authority ID (i.e., owning source)/Facility Name	Shoreline Pediatrics	Y
Patient ID: Type (e.g., medical record number, IIS ID)	Vendor supplied	Y
Patient Name: First	Juana	Y
Patient Name: Middle	Maria	Y
Patient Name: Last	Gonzales	Y
Patient Date of Birth	10/01/2018	Y
Birth Time	11:15am	N
Patient Gender (Administrative Sex)	F	Y
Patient Multiple Birth Indicator	Yes	Y
Patient Birth Order	2	Y
Responsible Person Name: First	Joanna	Y
Responsible Person Name: Middle	Elena	Y
Responsible Person Name: Last	Gonzales	Y
Responsible Person Name: Relationship to Patient	Mother	Y
Mother's Name: First	Joanna	Y
Mother's Name: Middle	Elena	Y
Mother's Name: Last	Gonzales	Y
Mother's Name: Maiden Last	Morales	Y
Patient Address: Street	3321 Standish Way	Y
Patient Address: City	Stamford	Y
Patient Address: State	CT	Y
Patient Address: Country	USA	Y
Patient Address: Zipcode	06903	Y
Patient Address: County of Residence	Fairfield	N
Race	White	Y
Ethnicity	Hispanic or Latino	Y
Birthing Facility Name (Birth Delivery Location Address BDL)	Stamford Regional Hospital 15 Atlantic Avenue, Stamford Connecticut 06903	[Y - birthing facility name, not address]
Patient Birth State	CT	Y
Patient Primary Language	English	Y
Patient Telephone Number	(203) 555-1214	Y
Patient Telephone Number Type (e.g., home, cell)	cell	Y
Patient E-mail Address	none	N
Publicity Code	Reminder/recall - no calls (03 HL70215)	Y
Protection Indicator	Yes	Y
Protection Indicator Effective Date	10/1/2018	Y
Immunization Registry Status		N
Preferred Contact Method	Text	Y

Notes

Protection Indicator Effective Date may use current date if constrained by EMR workflow.

Document in notable exceptions where Birth Address can not be captured/recorded by product.

1.5. Enter Inventory

Demonstrates the ability to enter and update inventory with stock received.

Test Story

Description
The provider enters vaccine inventory data from available inventory.

Comments
Barcodes are provided as an introductory option to enter the inventory.

Pre-condition
No PreCondition

Post-Condition
Vaccine inventory is recorded and available in the EMR.

Test Objectives

Update Vaccine Inventory from Stock Receipt: The EHR or other clinical software system updates the vaccine inventory when new stock is received at the site and updates the correct count of each vaccine, including those for use in guarantee programs (such as Vaccines for Children) and for private stock.

Display Available Vaccine Antigens: The system presents a list of vaccine antigens available for administration to patients (i.e., private stock Vs. specific guarantee program).

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
This test step is introduced in 2018 and will be considered an evaluation year for the test step. Tester should document feedback and issues. Tester may provide 2-D barcode images as a data input option.

1.5.1. Enter Vaccine Inventory

Test Step Type: SUT_MANUAL
Demonstrates the ability to enter and update inventory with stock received.

Test Story

Description
The provider receives a vaccine delivery and records the new vaccine data in available inventory.

Comments
Set-up step evaluating EMR functions for capturing and storing vaccine inventory data.

Pre-condition
No PreCondition

Post-Condition
Vaccine inventory is recorded and available in the EMR.

Test Objectives
Update Vaccine Inventory from Stock Receipt: The EHR or other clinical software system updates the vaccine inventory when new stock is received at the site and updates the correct count of each vaccine, including those for use in guarantee programs (such as Vaccines for Children) and for private stock.

Evaluation Criteria

Vendor successfully records all vaccine inventory data provided:

1. Manufacturer: Sanofi Pasteur Inc.
NDC:49281-0413-58
Product Name:FLUZONE QUADRIVALENT
Lot#:D8043IN8422
Expiration Date:12/31/2019
Vaccine source:VFC
Quantity:15 Vials (or doses)

2. Manufacturer: GlaxoSmithKline Biologicals SA
NDC:58160-0881-41
Product Name:FLUARIX
Lot#: 8L4B3521
Expiration Date:12/31/2019
Vaccine source:VFC
Quantity:12 Vials (or doses)

3. Manufacturer: Sanofi Pasteur Inc.
NDC:49281-0413-58
Product Name:FLUZONE QUADRIVALENT
Lot#:D8043IN8855

Expiration Date:12/31/2019
Vaccine source:Non-VFC
Quantity:12 Vials (or doses)

4. Manufacturer: GlaxoSmithKline Biologicals SA
NDC:58160-0820-43
Product Name:hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-43)
Lot#:6332FK18
Expiration Date:6/15/2018
Vaccine source:Non-VFC
Quantity:18 Syringes (or doses)

5. Manufacturer: GlaxoSmithKline Biologicals SA
NDC:58160-0820-43
Product Name:hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-43)
Lot#:6332FK26
Expiration Date:12/31/2019
Vaccine source:Non-VFC
Quantity:20 Syringes (or doses)

6. Manufacturer: GlaxoSmithKline Biologicals SA
NDC:58160-0811-43
Product Name:DTaP-hepatitis B and poliovirus vaccine (CVX 110) Pediarix (NDC 58160-0811-43)
Lot#:6559FK32
Expiration Date:12/31/2019
Vaccine source:Non-VFC
Quantity:16 Syringes (or doses)

Notes
This test step is introduced in 2018 and will be considered an evaluation year for the test step. Tester should document feedback and issues. Tester may provide 2-D barcode images as a data input option.

1.5.2. View Inventory

Test Step Type: SUT_MANUAL
Demonstrates the ability to view inventory supply.

Test Story

Description
The provider reviews the full list of vaccine inventory.

Comments
No Comments

Pre-condition
Inventory has been entered into the EMR.

Post-Condition
The list of available inventory is displayed.

Test Objectives
Display Available Vaccine Antigens: The system presents a list of vaccine antigens available for administration to patients (i.e., private stock Vs. specific guarantee program).

Evaluation Criteria

The EMR inventory shows (minimally):

1. Manufacturer: Sanofi Pasteur Inc.
NDC:49281-0413-58
Product Name:FLUZONE QUADRIVALENT
Lot#:D8043IN8422
Expiration Date:12/31/2019
Vaccine source:VFC
Quantity:15 Vials (or doses)

2. Manufacturer: Sanofi Pasteur Inc.
NDC:49281-0413-58
Product Name:FLUZONE QUADRIVALENT
Lot#:D8043IN8855

Expiration Date:12/31/2019
Vaccine source:Non-VFC
Quantity:12 Vials (or doses)

3. Manufacturer: GlaxoSmithKline Biologicals SA
NDC:58160-0820-43
Product Name:hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-43)
Lot#:6332FK18
Expiration Date:6/15/2018
Vaccine source:Non-VFC
Quantity:18 Syringes (or doses)

4. Manufacturer: GlaxoSmithKline Biologicals SA
NDC:58160-0820-43
Product Name:hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-43)
Lot#:6332FK26
Expiration Date:12/31/2019
Vaccine source:Non-VFC
Quantity:20 Syringes (or doses)

5. Manufacturer: GlaxoSmithKline Biologicals SA
NDC:58160-0811-43
Product Name:DTaP-hepatitis B and poliovirus vaccine (CVX 110) Pediarix (NDC 58160-0811-43)
Lot#:6559FK32
Expiration Date:12/31/2019
Vaccine source:Non-VFC
Quantity:16 Syringes (or doses)

Notes
This test step is introduced in 2018 and will be considered an evaluation year for the test step. Tester should document feedback and issues. Tester should also document how quantity is displayed and what is present (e.g. volume, # doses)

2. Juana Mariana Vazquez Visit

Juana Mariana Vazquez visits the provider where her immunization history is retrieved from the registry and reconciled with the local information in the medical record to determine vaccines that are due. Vaccinations are ordered and administered. The parents refuse the Polio vaccine due to prior issues. The vaccines are reported to the immunization registry and a vaccine summary is available for the patient.

Test Story

Description

Comments

Pre-condition

Post-Condition

Test Objectives

Evaluation Criteria

Notes

2.1. Query the Registry for Juana Mariana Vazquez

EMR generates a Z44 query to the Immunization Registry to retrieve the Evaluated History and Forecast for Juana Mariana Vazquez. The Z42 response is used to display, reconcile, and update the immunization information in the EMR.

Test Story

Description

The EMR generates a Z44 query to the Immunization Registry to retrieve the Evaluated History and Forecast for Juana Mariana Vazquez.
Querying the registry will consist of the vendor creating Z44 messages for Juana Mariana Vazquez to be sent to the registry. The response will be processed as part of the 'Display, Reconcile, Import and Update Immunization Information' activity.

Using the Z42 Response to Immunization Registry Query, the EMR displays the Evaluated History and Forecast to the user for reconciliation and update. The vendor will receive information back from the registry and show the ability to view and reconcile, and import the information returned by the registry (NOTE: the Z42 message will be provided either manually, or as part of the tool). This test will also look at the system's ability to view the forecast returned by the registry, and create a new forecast after reconciling the information.

Comments
No Comments

Pre-condition
Juana Mariana Vazquez is entered as a patient in the EMR with complete Demographic data, Immunization History Data, and Clinical Data according to the steps in the 'Juana Mariana Vazquez Initial Data Load'

Post-Condition
A Z44 Query is generated and submitted to the Immunization Registry/Test tool, and a Z42 response is returned.

Test Objectives

Select New Patient: The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information. For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother's maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient's information to external systems such as an immunization registry.

Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (QBP/RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5).

View Immunization Forecast: The system provides a view of the immunization forecast provided by the public health immunization registry (IIS). The display includes the forecast from the registry and includes recommended vaccination dates, minimum (earliest) date, date due, and maximum (latest) date for each vaccine included in the forecast.

View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient's newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service.

Review Patient Immunization History: To assist with the ordering process, the EHR or other clinical software system allows a user to specify standard views of patient immunization information for each vaccine dose administration, including patient-specific data (e.g., age on dates of administration, etc.).

Support for:
Receive Dose Not Indicated Alert for Single Vaccine Order: The EHR or other clinical software system notifies the provider in instances when there are single or combination vaccine orders that are inconsistent with the expected timing intervals included in the vaccine forecast. Inconsistencies include suggestion of different date(s) for ordering the vaccine(s) or indication the vaccine(s) is/are no longer required.

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
No Note

2.1.1. Select Patient Juana Mariana Vazquez

Test Step Type: SUT_MANUAL
Select patient Juana Mariana Vazquez, distinguishing the patient from other patients with similar demographics (similar names).

Test Story

Description
Juana Mariana Vazquez is selected as the patient and her record is opened in the EMR.

Comments
No Comments

Pre-condition
Juana Mariana Vazquez Initial Data Load completed.

Post-Condition
Juana Mariana Vazquez is the active working patient in the EMR.

Test Objectives

Select New Patient: The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information. For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother's maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient's information to external systems such as an immunization registry.

Evaluation Criteria

Tester shall verify that the product can distinguish Juana Mariana Vazquez from similar sounding names using all of the pediatric demographics. Tester verifies that the product can select the correct patient. The following subset of the patient demographic attributes entered during the initial data load are verified to assure that the correct patient is selected:

Patient Name: First - Juana
Patient Name: Middle - Mariana
Patient Date of Birth - 11/01/2013
Birth Time - 11:05
Patient Gender (Administrative Sex) - F
Patient Address: Street - 4345 Standish Way
Patient Address: City - Stamford
Patient Address: State - CT
Patient Address: Country - US
Patient Address: Zipcode - 06903
Patient Telephone Number - (203) 555-1212

Notes
No Note

2.1.2. Query Registry for vaccination history and forecast for Juana Mariana Vazquez

Test Step Type: SUT_INITIATOR
The EMR generates a Z44 query for immunization history and forecast correctly and without omission according to supplied test data.

Test Story

Description
The provider uses the EMR to query the Immunization Registry for an Evaluated History and Forecast based on information known to the Immunization Registry.

Comments
No Comments

Pre-condition

Juana Mariana Vazquez Initial Data Load is completed.

Juana Mariana Vazquez is the active working patient in the EMR.

Post-Condition
The Immunization Registry responds with Evaluated Vaccine History and Forecast for Juana Mariana Vazquez

Test Objectives

Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (QBP/RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5).

Support for:

Receive Dose Not Indicated Alert for Single Vaccine Order: The EHR or other clinical software system notifies the provider in instances when there are single or combination vaccine orders that are inconsistent with the expected timing intervals included in the vaccine forecast. Inconsistencies include suggestion of different date(s) for ordering the vaccine(s) or indication the vaccine(s) is/are no longer required.

Evaluation Criteria
Tester shall verify that the vendor can produce a valid Z44 query in accordance with the test data correctly and without omission. Tester shall verify that the data in the message corresponds to the data in the EMR and contains all test data attributes supplied.

Notes
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20181015001020-0500
MSH-9	Message Type
MSH-9.1	Message Code	QBP
MSH-9.2	Trigger Event	Q11
MSH-9.3	Message Structure	QBP_Q11
MSH-10	Message Control ID	793543
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z44
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

QPD : Query Parameter Definition

Location	Data Element	Data	Categorization
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number	123456
QPD-3.4	Assigning Authority
QPD-3.5	Identifier Type Code	MR
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Vazquez	Value-Test Case Fixed
QPD-4.2	Given Name	Juana	Value-Test Case Fixed
QPD-4.3	Second and Further Given Names or Initials Thereof	Mariana	Value-Test Case Fixed
QPD-4.7	Name Type Code	L	Value-Test Case Fixed
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Acosta	Value-Test Case Fixed
QPD-5.7	Name Type Code	M	Value-Test Case Fixed
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201311011105	Value-Test Case Fixed
QPD-7	Patient Sex	F	Value-Test Case Fixed
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	4345 Standish Way	Value-Test Case Fixed
QPD-8.2	Other Designation
QPD-8.3	City	Stamford	Value-Test Case Fixed
QPD-8.4	State or Province	CT	Value-Test Case Fixed
QPD-8.5	Zip or Postal Code	06903	Value-Test Case Fixed
QPD-8.6	Country
QPD-8.7	Address Type	L	Value-Test Case Fixed
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN	Value-Test Case Fixed
QPD-9.3	Telecommunication Equipment Type	CP	Value-Test Case Fixed
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203	Value-Test Case Fixed
QPD-9.7	Local Number	5551212	Value-Test Case Fixed
QPD-10	Multiple birth indicator	N	Indifferent
QPD-11	Birth order

RCP : Response Control Parameter

Location	Data Element	Data
RCP-1	Query Priority	I
RCP-2	Quantity Limited Request
RCP-2.1	Quantity	1
RCP-2.2	Units
RCP-2.2.1	Identifier	RD
RCP-2.2.2	Text	Records
RCP-2.2.3	Name of Coding System	HL70126

Test Data Specification

Patient Information

Element	Data
Patient Name	Juana Mariana Vazquez
Mother's Maiden Name	Acosta
ID Number	123456
Date/Time of Birth	11/01/2013 11:05
Sex	Female
Patient Address	4345 Standish Way Stamford CT 06903
Patient Phone	(203)555-1212
Birth Indicator	No
Birth Order

2.1.3. View and Compare response to request for vaccination history for Juana Mariana Vazquez

Test Step Type: TA_RESPONDER
The EMR displays the Immunization History results (Z42) returned in response to the Z44 Query and compare to those in the EMR.

Test Story

Description

The Immunization Registry returns an Evaluated History and Forecast (Z42) to the EMR in response to the query for patient (Juana Mariana Vazquez). The provider reviews the immunization history from the registry and compares to the immunization history in the EMR. The provider reviews the information from these sources, identifying information known only to the registry, and identifying information that is more accurately reflected in the local EMR:

The physician accesses the record for Juana Mariana Vazquez and the EHR Differentiates:

The following vaccinations are available only to the EMR:

- diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 11/20/2016

- poliovirus vaccine, inactivated (CVX 10) administered 2/21/2014,

o Adverse Reaction: febrile seizure (e.g. Simple febrile seizure (finding) 432354000) VXC11^convulsions (fits, seizures) within 72 hours of dose^CDCPHINV)

- Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/15/2017,

The EHR differentiates the following vaccinations which differ between the EMR and the IIS:

- For the hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 12/20/2013, that EMR displays different text for the IIS (which documents a Non-specific formulation) and EMR (which documents hepatitis B vaccine, pediatric or pediatric/adolescent dosage) for Vaccine administered

The EHR differentiates the following vaccinations that are available from both the IIS that and the local EMR:

- measles, mumps, rubella virus vaccine (CVX 03 ) administered 8/22/2014 (an invalid dose)

- poliovirus vaccine, inactivated (CVX 10) administered 2/21/2015,

o Adverse Reaction: febrile seizure (e.g. Simple febrile seizure (finding) 432354000) VXC11^convulsions (fits, seizures) within 72 hours of dose^CDCPHINV)

The EHR differentiates the following vaccinations are that are available from the IIS that are not known to the local EMR:

- hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 11/01/2013

- hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 05/20/2014

- diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 1/22/2014

- diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 3/23/2014,

- diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 5/22/2014

- diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 2/21/2015

- Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 1/22/2014

- Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 3/23/2014

- Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 5/22/2014

- Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 11/21/2014

- poliovirus vaccine, inactivated (CVX 10) administered 1/22/2014

- poliovirus vaccine, inactivated (CVX 10) administered 3/23/2014

- pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 1/22/2014

- pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 3/23/2014

- pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 5/22/2014

- pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 1/11/2015

- rotavirus, live, monovalent vaccine (CVX 119) administered 1/22/2014

- rotavirus, live, monovalent vaccine (CVX 119) administered 3/23/2014

- Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 9/25/2014

- Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/29/2014

- Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/2/2015

- Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 11/4/2016

- hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) administered 11/23/2014

- hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) administered 5/23/2015

- measles, mumps, rubella virus vaccine (CVX 03) administered 11/22/2017

- Varicella virus vaccine (CVX 21) administered 12/15/2015

Comments
No Comments

Pre-condition

Juana Mariana Vazquez Initial Data Load is completed.

Juana Mariana Vazquez is the active working patient in the EMR.

A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.

Post-Condition
Evaluated Immunization History returned from the registry is reviewed and compared to the immunizations in the patient record (Juana Mariana Vazquez)

Test Objectives

Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5).

Compare Public Health Immunization Registry (IIS) Immunization History to EHR Immunization History: The public health immunization registry has returned the requested immunization history for a patient. The EHR is able to display the immunization history received from the registry as well as the immunization history already present in the EHR so that a user can compare them. The EHR provides a way for the provider to view both histories, determine what is different (if anything), and update the existing EHR immunization history with new information from the public health registry if he or she chooses to do so. The system must store the new information as structured data as part of the patient's local immunization history and include the time of the update and the source of the new information.

Review Patient Immunization History: To assist with the ordering process, the EHR or other clinical software system allows a user to specify standard views of patient immunization information for each vaccine dose administration, including patient-specific data (e.g., age on dates of administration, etc.).

Support for:
Receive Dose Not Indicated Alert for Single Vaccine Order: The EHR or other clinical software system notifies the provider in instances when there are single or combination vaccine orders that are inconsistent with the expected timing intervals included in the vaccine forecast. Inconsistencies include suggestion of different date(s) for ordering the vaccine(s) or indication the vaccine(s) is/are no longer required.

Evaluation Criteria

1. The EMR is able to receive the response from the Immunization Registry.

2. The EMR displays the information returned from the Immunization Registry according to the Juror Document.

- Complete review for Polio administered 3/23/2013, MMR 8/22/2013
- remaining vaccines may be reviewed only for the vaccine name and date administered

3. The EMR is able to differentiate the vaccines in the comparison between the EHR and the vaccination history

Notes

The juror document also contains the verification content for the immunization forecast, which is tested and graded separately at step 5: View the vaccination history for Juana Mariana Vazquez. The criteria for this step is tested separately here and graded only with respect to the vaccine history.

Visualization of the adverse reaction for the Polio Vaccine in the history returned from the IIS is an advanced function. The adverse event is returned in the message and may be displayed during comparison by the EMR, but it is not listed in the Juror document.

The EMR must minimally display the vaccine administered and the date of the immunization.

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20181015001020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	793543

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	37374859
QAK-2	Query Response Status	OK
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Vazquez
QPD-4.2	Given Name	Juana
QPD-4.3	Second and Further Given Names or Initials Thereof	Mariana
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Acosta
QPD-5.7	Name Type Code	M
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201311011105
QPD-7	Patient Sex	F
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	4345 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	CP
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551212
QPD-10	Multiple birth indicator
QPD-11	Birth order

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Vazquez
PID-5.2	Given Name	Juana
PID-5.3	Second and Further Given Names or Initials Thereof	Mariana
PID-5.7	Name Type Code	L
PID-7	Date/Time of Birth
PID-7.1	Time	201311011105
PID-8	Administrative Sex	F
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	4345 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Shoreline Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20131101
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20131220
RXA-5	Administered Code
RXA-5.1	Identifier	45
RXA-5.2	Text	hepatitis B vaccine, unspecified formulation
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140520
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140122
RXA-5	Administered Code
RXA-5.1	Identifier	107
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140323
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140522
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150221
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140122
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140323
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140522
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141121
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140122
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140323
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140122
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140323
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140522
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150111
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140122
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	rotavirus, live, monovalent vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140323
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	rotavirus, live, monovalent vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140925
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141029
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151002
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20161104
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141123
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150523
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140822
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20171122
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151215
RXA-5	Administered Code
RXA-5.1	Identifier	21
RXA-5.2	Text	varicella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140429
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181021
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38288
RXR-1.2	Text	Oral
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38288
RXR-1.2	Text	Oral
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	hepatitis B vaccine, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20131031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	hepatitis B vaccine, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20131031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	hepatitis B vaccine, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140520

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140122

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140122

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20140122
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140323

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140323

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20140323
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140522

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140522

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20140522
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140221

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150221

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150221
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140122

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140323

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140522

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141121

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140122

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	31044-1
OBX-3.2	Text	Reaction
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC11
OBX-5.2	Text	convulsions (fits, seizures) within 72 hours of dose
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100523

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140323

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140122

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140323

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140522

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150111

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140122

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140323

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140925

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141029

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151002

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20161104

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141123

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20111025
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141123

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141123
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300004211111025
OBX-5.2	Text	Hepatitis A VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150523

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20111025
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150523

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150523
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300004211111025
OBX-5.2	Text	Hepatitis A VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140822

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	N
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30982-3
OBX-3.2	Text	Reason code
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	264499004
OBX-5.2	Text	Early
OBX-5.3	Name of Coding System	SCT
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151122

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella virus vaccine
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151215

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140429

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20140429
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20140429
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150430
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140429

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181021

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20171031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20171031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20191031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20171031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20171031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20191031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

Juror Document

Evaluated Immunization History and Immunization Forecast

Test Case ID

Query the Registry for Juana Mariana Vazquez

Inspection Settlement (Pass/Fail)

Pass	Fail

Reason Failed

Juror Comments

DISPLAY VERIFICATION

This Test Case-specific Juror Document provides a checklist for the Tester to use during certification testing for assessing the EHR technology's ability to display required core data elements from the information received in the Evaluated Immunization History and Immunization Forecast Z42 response message. Additional data from the message or from the EHR are permitted to be displayed by the EHR. Grayed-out fields in the Juror Document indicate where no data for the data element indicated were included in the Z42 message for the given Test Case.

The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.

The Evaluated Immunization History and Immunization Forecast data shown in this Juror Document are derived from the Z42 message provided with the given Test Case; equivalent data are permitted to be displayed by the EHR. The column headings are meant to convey the kind of data to be displayed; equivalent labels/column headings are permitted to be displayed by the EHR.

Patient Information
Element Name	Data	Tester Comment
Patient Identifier
ID Number	123456
Assigning Authority
Namespace ID	MYEHR
ID Type	MR
Patient Identifier
ID Number	987633
Assigning Authority
Namespace ID	MYIIS
ID Type	SR
Name	Juana Mariana Vazquez
Date of Birth	11/01/2013
Sex	Female
Address 1
Street	4345 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country	USA
Address Type	L
Mother's Maiden Name	Maria Merida Acosta
When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient.

Evaluated Immunization History Information
Element Name	Data	Tester Comment
Entering Organization	Shoreline Hospital
Vaccine Group	hepatitis B vaccine, unspecified formulation
Vaccine Administered	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Refusal Reason
Date/Time Administration-Start	11/01/2013
Date/Time Administration-End	11/01/2013
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	hepatitis B vaccine, unspecified formulation
Vaccine Administered	hepatitis B vaccine, unspecified formulation
Refusal Reason
Date/Time Administration-Start	12/20/2013
Date/Time Administration-End	12/20/2013
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Right Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	hepatitis B vaccine, unspecified formulation
Vaccine Administered	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Refusal Reason
Date/Time Administration-Start	05/20/2014
Date/Time Administration-End	05/20/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Refusal Reason
Date/Time Administration-Start	01/22/2014
Date/Time Administration-End	01/22/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Refusal Reason
Date/Time Administration-Start	03/23/2014
Date/Time Administration-End	03/23/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Right Thigh
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Refusal Reason
Date/Time Administration-Start	05/22/2014
Date/Time Administration-End	05/22/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Refusal Reason
Date/Time Administration-Start	02/21/2015
Date/Time Administration-End	02/21/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Refusal Reason
Date/Time Administration-Start	01/22/2014
Date/Time Administration-End	01/22/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Right Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Refusal Reason
Date/Time Administration-Start	03/23/2014
Date/Time Administration-End	03/23/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Refusal Reason
Date/Time Administration-Start	05/22/2014
Date/Time Administration-End	05/22/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Right Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Refusal Reason
Date/Time Administration-Start	11/21/2014
Date/Time Administration-End	11/21/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Deltoid
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	poliovirus vaccine, inactivated
Vaccine Administered	poliovirus vaccine, inactivated
Refusal Reason
Date/Time Administration-Start	01/22/2014
Date/Time Administration-End	01/22/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Subcutaneous
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	poliovirus vaccine, inactivated
Vaccine Administered	poliovirus vaccine, inactivated
Refusal Reason
Date/Time Administration-Start	03/23/2014
Date/Time Administration-End	03/23/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Subcutaneous
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	pneumococcal conjugate vaccine, 13 valent
Refusal Reason
Date/Time Administration-Start	01/22/2014
Date/Time Administration-End	01/22/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	pneumococcal conjugate vaccine, 13 valent
Refusal Reason
Date/Time Administration-Start	03/23/2014
Date/Time Administration-End	03/23/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	pneumococcal conjugate vaccine, 13 valent
Refusal Reason
Date/Time Administration-Start	05/22/2014
Date/Time Administration-End	05/22/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Right Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	pneumococcal conjugate vaccine, 13 valent
Refusal Reason
Date/Time Administration-Start	01/11/2015
Date/Time Administration-End	01/11/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Deltoid
Substance Manufacturer Name	Pfizer, Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	rotavirus, unspecified formulation
Vaccine Administered	rotavirus, live, monovalent vaccine
Refusal Reason
Date/Time Administration-Start	01/22/2014
Date/Time Administration-End	01/22/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Oral
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	rotavirus, unspecified formulation
Vaccine Administered	rotavirus, live, monovalent vaccine
Refusal Reason
Date/Time Administration-Start	03/23/2014
Date/Time Administration-End	03/23/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Oral
Administration Site	Right Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza, injectable,quadrivalent, preservative free, pediatric
Refusal Reason
Date/Time Administration-Start	09/25/2014
Date/Time Administration-End	09/25/2014
Administered Amount	0.25
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi Pasteur
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza, injectable,quadrivalent, preservative free, pediatric
Refusal Reason
Date/Time Administration-Start	10/29/2014
Date/Time Administration-End	10/29/2014
Administered Amount	0.25
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Right Thigh
Substance Manufacturer Name	Sanofi Pasteur
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza, injectable,quadrivalent, preservative free, pediatric
Refusal Reason
Date/Time Administration-Start	10/02/2015
Date/Time Administration-End	10/02/2015
Administered Amount	.25
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose
Validity Reason
Completion Status*	Complete
Dose Number in Series
Number of Doses in Series
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza, injectable,quadrivalent, preservative free, pediatric
Refusal Reason
Date/Time Administration-Start	11/04/2016
Date/Time Administration-End	11/04/2016
Administered Amount	0.25
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose
Validity Reason
Completion Status*	Complete
Dose Number in Series
Number of Doses in Series
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hep A, unspecified formulation
Vaccine Administered	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Refusal Reason
Date/Time Administration-Start	11/23/2014
Date/Time Administration-End	11/23/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Right Deltoid
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hep A, unspecified formulation
Vaccine Administered	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Refusal Reason
Date/Time Administration-Start	05/23/2015
Date/Time Administration-End	05/23/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Deltoid
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Shoreline Pediatrics
Vaccine Group	MMR
Vaccine Administered	measles, mumps, rubella virus vaccine
Refusal Reason
Date/Time Administration-Start	08/22/2014
Date/Time Administration-End	08/22/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Subcutaneous
Administration Site	Left Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	Sandra Molina
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	400 Shoreline Drive
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	NO
Validity Reason	Early
Completion Status*	Complete
Dose Number in Series
Number of Doses in Series
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	MMR
Vaccine Administered	measles, mumps, rubella virus vaccine
Refusal Reason
Date/Time Administration-Start	11/22/2017
Date/Time Administration-End	11/22/2017
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Subcutaneous
Administration Site	Left Deltoid
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Varicella virus vaccine
Vaccine Administered	varicella virus vaccine
Refusal Reason
Date/Time Administration-Start	12/15/2015
Date/Time Administration-End	12/15/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Subcutaneous
Administration Site	Right Deltoid
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

* "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered".

Immunization Forecast
Element Name	Data	Tester Comment
Vaccine Group	IPV
Vaccine Due Date	04/29/2014
Earliest Date to Give	04/29/2014
Latest Date to Give
Date When Vaccine Overdue	04/30/2015
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	influenza, unspecified formulation
Vaccine Due Date	09/01/2018
Earliest Date to Give	09/01/2018
Latest Date to Give
Date When Vaccine Overdue	10/31/2019
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	MMR
Vaccine Due Date	10/31/2017
Earliest Date to Give	10/31/2017
Latest Date to Give
Date When Vaccine Overdue	10/31/2019
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Varicella
Vaccine Due Date	10/31/2017
Earliest Date to Give	10/31/2017
Latest Date to Give
Date When Vaccine Overdue	10/31/2019
Status in Immunization Series
Forecast Reason

2.1.4. Mark first MMR Dose as Invalid

Test Step Type: SUT_MANUAL
Identify the first MMR dose which is given too early, as invalid. If the EHR does not already flagged the first MMR as invalid, the provider updates the first MMR to indicate it is "invalid "as it was given too early (as notified by the registry).

Test Story

Description
If the EHR does not already flag the first MMR as invalid, the provider updates the first MMR to indicate it is "invalid" as it was given too early (as notified by the registry)

Comments
If the EMR already recognizes the dose as invalid, then this step may be skipped.

Pre-condition

Initial Data Load -

Step 2: Enter Initial Immunization Data for Juana Mariana Vazquez: Immunizations from practice

Post-Condition
MMR status for the first MMR dose is set to invalid.

Test Objectives

dose validity is an important aspect of:

Evaluation Criteria

Evaluation Criteria: The vendor is able to record that the first MMR vaccination dose is invalid with a reason that it was given too early, and therefore the dose administered on 11/22/2017 should indicated dose '1'.

Notes

In the steps that follow, the MMR returned from the registry will be imported and the vaccine forecasting steps wil further verify the correct documentation of the dose that will be imported from the registry as dose '1'.

2.1.5. View the vaccination forecast for Juana Mariana Vazquez

Test Step Type: TA_RESPONDER
Vendor can successfully display the current Immunization Forecast (vaccination names and recommended vaccination dates) as returned by the Registry (Z42).

Test Story

Description

The physician accesses the record for Juana Mariana Vazquez and:

- Displays the registry forecast as returned by the immunization registry

Comments
No Comments

Pre-condition
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.

Post-Condition
Immunization Forecast returned from the registry has been displayed to the user.

Test Objectives
View Immunization Forecast: The system provides a view of the immunization forecast provided by the public health immunization registry (IIS). The display includes the forecast from the registry and includes recommended vaccination dates, minimum (earliest) date, date due, and maximum (latest) date for each vaccine included in the forecast.

Evaluation Criteria

1. The EMR displays the information returned from the Immunization Registry according to the Juror Document.

2. Verify that all forecast vaccines and dates returned by the registry are displayed to the user.

Notes

The verification content for the vaccine forecast also is part of the juror document in the prior step 3: View and Compare response to request for vaccination history for Juana Mariana Vazquez. The criteria for this step is tested separately here and graded only with respect to the vaccine forecast. Date when Vaccine Overdue may be omitted for the Influenza Vaccine.

For MMR, the 2nd dose is due 10/31/17 according to the schedule. Since the first one was given too early, the child is behind. Verify that the EMR shows all 3 dates returned by the registry:

- Earliest Date to Give

- Vaccine Due Date

- Date When Vaccine Overdue

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20181015001020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	793543

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	37374859
QAK-2	Query Response Status	OK
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Vazquez
QPD-4.2	Given Name	Juana
QPD-4.3	Second and Further Given Names or Initials Thereof	Mariana
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Acosta
QPD-5.7	Name Type Code	M
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201311011105
QPD-7	Patient Sex	F
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	4345 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	CP
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551212
QPD-10	Multiple birth indicator
QPD-11	Birth order

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Vazquez
PID-5.2	Given Name	Juana
PID-5.3	Second and Further Given Names or Initials Thereof	Mariana
PID-5.7	Name Type Code	L
PID-7	Date/Time of Birth
PID-7.1	Time	201311011105
PID-8	Administrative Sex	F
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	4345 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Shoreline Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20131101
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20131220
RXA-5	Administered Code
RXA-5.1	Identifier	45
RXA-5.2	Text	hepatitis B vaccine, unspecified formulation
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140520
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140122
RXA-5	Administered Code
RXA-5.1	Identifier	107
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140323
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140522
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150221
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140122
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140323
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140522
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141121
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140122
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140323
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	poliovirus vaccine, inactivated
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140122
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140323
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140522
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150111
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140122
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	rotavirus, live, monovalent vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140323
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	rotavirus, live, monovalent vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140925
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141029
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151002
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20161104
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141123
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150523
RXA-5	Administered Code
RXA-5.1	Identifier	83
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140822
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20171122
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151215
RXA-5	Administered Code
RXA-5.1	Identifier	21
RXA-5.2	Text	varicella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text	new immunization record
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140429
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181021
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38288
RXR-1.2	Text	Oral
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38288
RXR-1.2	Text	Oral
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	hepatitis B vaccine, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20131031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	hepatitis B vaccine, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20131031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	hepatitis B vaccine, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140520

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140122

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140122

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20140122
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140323

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140323

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20140323
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140522

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140522

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20140522
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140221

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20070517
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150221

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150221
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	8
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300003511070517
OBX-5.2	Text	Diphtheria/Tetanus/Pertussis (DTaP) VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140122

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140323

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140522

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141121

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140122

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	31044-1
OBX-3.2	Text	Reaction
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC11
OBX-5.2	Text	convulsions (fits, seizures) within 72 hours of dose
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20100523

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140323

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140122

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140323

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140522

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150111

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140122

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140323

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140925

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141029

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151002

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20161104

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141123

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20111025
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20141123

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20141123
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300004211111025
OBX-5.2	Text	Hepatitis A VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150523

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	VIS Publication Date
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20111025
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150523

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	VIS presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150523
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9
OBX-3.2	Text	Document type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300004211111025
OBX-5.2	Text	Hepatitis A VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140822

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	N
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30982-3
OBX-3.2	Text	Reason code
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	264499004
OBX-5.2	Text	Early
OBX-5.3	Name of Coding System	SCT
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151122

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella virus vaccine
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20151215

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140429

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20140429
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20140429
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20150430
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20140429

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181021

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20171031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20171031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20191031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20171031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20171031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20191031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	7
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

Juror Document

Evaluated Immunization History and Immunization Forecast

Test Case ID

Query the Registry for Juana Mariana Vazquez

Inspection Settlement (Pass/Fail)

Pass	Fail

Reason Failed

Juror Comments

DISPLAY VERIFICATION

The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.

Patient Information
Element Name	Data	Tester Comment
Patient Identifier
ID Number	123456
Assigning Authority
Namespace ID	MYEHR
ID Type	MR
Patient Identifier
ID Number	987633
Assigning Authority
Namespace ID	MYIIS
ID Type	SR
Name	Juana Mariana Vazquez
Date of Birth	11/01/2013
Sex	Female
Address 1
Street	4345 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country	USA
Address Type	L
Mother's Maiden Name	Maria Merida Acosta
When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient.

Evaluated Immunization History Information
Element Name	Data	Tester Comment
Entering Organization	Shoreline Hospital
Vaccine Group	hepatitis B vaccine, unspecified formulation
Vaccine Administered	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Refusal Reason
Date/Time Administration-Start	11/01/2013
Date/Time Administration-End	11/01/2013
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	hepatitis B vaccine, unspecified formulation
Vaccine Administered	hepatitis B vaccine, unspecified formulation
Refusal Reason
Date/Time Administration-Start	12/20/2013
Date/Time Administration-End	12/20/2013
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Right Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	hepatitis B vaccine, unspecified formulation
Vaccine Administered	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Refusal Reason
Date/Time Administration-Start	05/20/2014
Date/Time Administration-End	05/20/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Refusal Reason
Date/Time Administration-Start	01/22/2014
Date/Time Administration-End	01/22/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Refusal Reason
Date/Time Administration-Start	03/23/2014
Date/Time Administration-End	03/23/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Right Thigh
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Refusal Reason
Date/Time Administration-Start	05/22/2014
Date/Time Administration-End	05/22/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Refusal Reason
Date/Time Administration-Start	02/21/2015
Date/Time Administration-End	02/21/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Refusal Reason
Date/Time Administration-Start	01/22/2014
Date/Time Administration-End	01/22/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Right Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address
Other Designation
City
State
Zip Code
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Refusal Reason
Date/Time Administration-Start	03/23/2014
Date/Time Administration-End	03/23/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Refusal Reason
Date/Time Administration-Start	05/22/2014
Date/Time Administration-End	05/22/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Right Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Refusal Reason
Date/Time Administration-Start	11/21/2014
Date/Time Administration-End	11/21/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Deltoid
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	poliovirus vaccine, inactivated
Vaccine Administered	poliovirus vaccine, inactivated
Refusal Reason
Date/Time Administration-Start	01/22/2014
Date/Time Administration-End	01/22/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Subcutaneous
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	poliovirus vaccine, inactivated
Vaccine Administered	poliovirus vaccine, inactivated
Refusal Reason
Date/Time Administration-Start	03/23/2014
Date/Time Administration-End	03/23/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Subcutaneous
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	pneumococcal conjugate vaccine, 13 valent
Refusal Reason
Date/Time Administration-Start	01/22/2014
Date/Time Administration-End	01/22/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	pneumococcal conjugate vaccine, 13 valent
Refusal Reason
Date/Time Administration-Start	03/23/2014
Date/Time Administration-End	03/23/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	pneumococcal conjugate vaccine, 13 valent
Refusal Reason
Date/Time Administration-Start	05/22/2014
Date/Time Administration-End	05/22/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Right Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	pneumococcal conjugate vaccine, 13 valent
Refusal Reason
Date/Time Administration-Start	01/11/2015
Date/Time Administration-End	01/11/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Deltoid
Substance Manufacturer Name	Pfizer, Inc
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	rotavirus, unspecified formulation
Vaccine Administered	rotavirus, live, monovalent vaccine
Refusal Reason
Date/Time Administration-Start	01/22/2014
Date/Time Administration-End	01/22/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Oral
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	rotavirus, unspecified formulation
Vaccine Administered	rotavirus, live, monovalent vaccine
Refusal Reason
Date/Time Administration-Start	03/23/2014
Date/Time Administration-End	03/23/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Oral
Administration Site	Right Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza, injectable,quadrivalent, preservative free, pediatric
Refusal Reason
Date/Time Administration-Start	09/25/2014
Date/Time Administration-End	09/25/2014
Administered Amount	0.25
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi Pasteur
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza, injectable,quadrivalent, preservative free, pediatric
Refusal Reason
Date/Time Administration-Start	10/29/2014
Date/Time Administration-End	10/29/2014
Administered Amount	0.25
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Right Thigh
Substance Manufacturer Name	Sanofi Pasteur
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza, injectable,quadrivalent, preservative free, pediatric
Refusal Reason
Date/Time Administration-Start	10/02/2015
Date/Time Administration-End	10/02/2015
Administered Amount	.25
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose
Validity Reason
Completion Status*	Complete
Dose Number in Series
Number of Doses in Series
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza, injectable,quadrivalent, preservative free, pediatric
Refusal Reason
Date/Time Administration-Start	11/04/2016
Date/Time Administration-End	11/04/2016
Administered Amount	0.25
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose
Validity Reason
Completion Status*	Complete
Dose Number in Series
Number of Doses in Series
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hep A, unspecified formulation
Vaccine Administered	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Refusal Reason
Date/Time Administration-Start	11/23/2014
Date/Time Administration-End	11/23/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Right Deltoid
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hep A, unspecified formulation
Vaccine Administered	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Refusal Reason
Date/Time Administration-Start	05/23/2015
Date/Time Administration-End	05/23/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Deltoid
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Shoreline Pediatrics
Vaccine Group	MMR
Vaccine Administered	measles, mumps, rubella virus vaccine
Refusal Reason
Date/Time Administration-Start	08/22/2014
Date/Time Administration-End	08/22/2014
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Subcutaneous
Administration Site	Left Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	Sandra Molina
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	400 Shoreline Drive
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	NO
Validity Reason	Early
Completion Status*	Complete
Dose Number in Series
Number of Doses in Series
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	MMR
Vaccine Administered	measles, mumps, rubella virus vaccine
Refusal Reason
Date/Time Administration-Start	11/22/2017
Date/Time Administration-End	11/22/2017
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Subcutaneous
Administration Site	Left Deltoid
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Varicella virus vaccine
Vaccine Administered	varicella virus vaccine
Refusal Reason
Date/Time Administration-Start	12/15/2015
Date/Time Administration-End	12/15/2015
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Subcutaneous
Administration Site	Right Deltoid
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Administration Notes	new immunization record
Administering Provider
Name	J Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	333 Oceanview Lane
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

* "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered".

Immunization Forecast
Element Name	Data	Tester Comment
Vaccine Group	IPV
Vaccine Due Date	04/29/2014
Earliest Date to Give	04/29/2014
Latest Date to Give
Date When Vaccine Overdue	04/30/2015
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	influenza, unspecified formulation
Vaccine Due Date	09/01/2018
Earliest Date to Give	09/01/2018
Latest Date to Give
Date When Vaccine Overdue	10/31/2019
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	MMR
Vaccine Due Date	10/31/2017
Earliest Date to Give	10/31/2017
Latest Date to Give
Date When Vaccine Overdue	10/31/2019
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Varicella
Vaccine Due Date	10/31/2017
Earliest Date to Give	10/31/2017
Latest Date to Give
Date When Vaccine Overdue	10/31/2019
Status in Immunization Series
Forecast Reason

2.1.6. Reconcile and import vaccinations from Evaluated History and Forecast for Juana Mariana Vazquez

Test Step Type: SUT_MANUAL
The Provider uses the EMR to compare the immunization history results (Z42) returned by the Immunization Registry in response to the Z44 Query with the immunization history in the local system, and reconcile (import/update) records.

Test Story

Description
Juana Mariana Vazquez immunization registry provided Evaluated History and Forecast is reconciled with the Immunization history information in the EMR.

Comments
No Comments

Pre-condition
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import.

Post-Condition
Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juana Mariana Vazquez)

Test Objectives

Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry.

Support for:

Evaluation Criteria

1. The user imports the vaccination, date administered, and documents adverse reactions reconciled from the returned vaccinations as follows:

a. Vaccinations NOT imported:

hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 45) administered 12/20/2013

measles, mumps, and rubella virus vaccine (CVX 03) administered 8/22/2014

diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 11/20/2017 [known only to EMR, not available from IIS]

poliovirus vaccine, inactivated (CVX 10) administered 2/21/2015 [known only to EMR, not available from IIS]

Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 140) administered 10/15/2017 [known only to EMR, not available from IIS]

b. Vaccinations Imported:

hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 11/01/2013

hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 05/20/2014

diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 1/22/2014

diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 3/23/2014

diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 5/22/2014

diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 2/21/2015

Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 1/22/2014

Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 3/23/2014

Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 5/22/2014

Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 11/21/2014

poliovirus vaccine, inactivated (CVX 10) administered 1/22/2014

poliovirus vaccine, inactivated (CVX 10) administered 3/23/2014

pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 1/22/2014

pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 3/23/2014

pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 5/22/2014

pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 1/11/2015

rotavirus, live, monovalent vaccine (CVX 119) administered 1/22/2014

rotavirus, live, monovalent vaccine (CVX 119) administered 3/23/2014

Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 9/25/2014

Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/29/2014

Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/2/2015

Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 11/4/2016

hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) administered 11/23/2014

hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) administered 5/23/2015

measles, mumps, rubella virus vaccine (CVX 03) administered 11/22/2017

Varicella virus vaccine (CVX 21) administered 12/15/2015

2. The tester verifies that the Reconciled Patient Immunization History can be displayed to the user.

Notes
No Note

2.1.7. View the updated vaccination forecast for Juana Mariana Vazquez

Test Step Type: SUT_MANUAL
Using the reconciled vaccine history information, the EMR displays the current Immunization Forecast to the user for Juana Mariana Vazquez.

Test Story

Description
Once the vaccine history is reconciled in the EMR, the vaccine forecast is updated.

Comments
No Comments

Pre-condition
EMR Vaccine History is Reconciled with Immunization History from the IIS (previous step 'Reconcile and import vaccinations from Evaluated History and Forecast returned by the Registry for Juana Mariana Vazquez').

Post-Condition
An updated vaccine forecast based upon the reconciled vaccine history is available to the user.

Test Objectives

View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient's newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service.

Evaluation Criteria

Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history:

1. Verify that the EMR does not include in reconciled vaccine forecast:

IPV due on 4/30/2014

2. Verify that the EMR includes in reconciled vaccine forecast:

IPV due on 10/31/2017

Varicella due on 10/31/2017

influenza, unspecified formulation due on 09/01/2018 or later (annual recommendation - specific date may vary somewhat)

Notes

The due date must be in range for the date shown. Vaccine forecast dates may be plus or minus 10 days to accommodate differences in date handling.

Further variation should be documented in the notable exceptions, but minimally each forecast vaccine must be present.

2.2. Juana Mariana Vazquez, Enter Orders and Immunizations

Orders and Immunization events, non-administrations, and alerts presented for current visit.

Test Story

Description
This test will consist of ordering vaccines for the test patients, reviewing any alerts caused by specific scenarios, and documenting vaccinations administered to the patients.

Comments
No Comments

Pre-condition
Juana Mariana Vazquez is entered as a patient in the EMR with complete Demographic data, Immunization History Data, and Clinical Data according to the steps in the 'Juana Mariana Vazquez Initial Data Load'

Post-Condition
Visit orders are entered in Juana Mariana Vazquez' record.

Test Objectives

Notify of Previous Adverse Event: EHRs and other clinical software systems alert providers to previous adverse events for a specific patient, in order to inform clinical decision-making when providers view an existing immunization record.

Record Vaccine Administration Deferral: The EHR or other clinical software system allows a user to enter a reason or reasons why a specific immunization was not given to a patient (e.g., due to contraindication, refusal, etc.). The system also stores that information in a structured way so it can be reported and analyzed as needed.

Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered. The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size.

Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines.

Sample of data quality checking for vaccine route.

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
No Note

2.2.1. Order IPV and view prior reaction

Test Step Type: SUT_MANUAL
The provider selects to order IPV and views information about the prior febrile seizure post-IPV vaccine.

Test Story

Description

The physician accesses the record for Juana Mariana Vazquez and:

- Selects order for IPV and views information about the prior febrile seizure post-IPV vaccine

- IPV is ordered for the patient

Comments
In this step, the order is recorded after receiving the alert. This step is followed by parental refusal when the administration is attempted.

Pre-condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR.

Post-Condition
IPV order entered in patient record. User notified of history of adverse reaction to IPV (febrile seizures).

Test Objectives

Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines.

Notify of Previous Adverse Event: EHRs and other clinical software systems alert providers to previous adverse events for a specific patient, in order to inform clinical decision-making when providers view an existing immunization record.

Evaluation Criteria

EMR Records the following order information and Alert. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source	New immunization record (NIP001 00)
Value/Text for Vaccine Type	IPV (CVX 10)
Date/Time Vaccine Refusal was recorded	Current Date
Alert	Alerts user to information about the prior febrile seizure post-IPV vaccine

Notes
No Note

2.2.2. IPV Parental Refusal

Test Step Type: SUT_MANUAL
Documents mother's refusal for IPV vaccine indicating the parent decision, the reason and documents a deferral.

Test Story

Description
The mother is concerned about administering the IPV due to the prior adverse reaction, and refuses to have the child immunized for IPV. The provider documents mother's refusal for IPV vaccine indicating the parent decision, the reason and documents a deferral at the time of attempted administration.

Comments
No Comments

Pre-condition
Prior Immunization History loaded and reconciled from the Immunization Registry. Order is entered for IPV. Provider has been alerted to prior adverse reaction to IPV of febrile seizures.

Post-Condition
Vaccine non-administration due to parental refusal is documented in the patient record. Deferral is recorded.

Test Objectives
Record Vaccine Administration Deferral: The EHR or other clinical software system allows a user to enter a reason or reasons why a specific immunization was not given to a patient (e.g., due to contraindication, refusal, etc.). The system also stores that information in a structured way so it can be reported and analyzed as needed.

Evaluation Criteria

EMR documents the non-administration of the IPV due to the parental refusal. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions::

Substance/Treatment Refusal Reason	Parental decision (NIP002 00)
Completion Status	RE
Date/Time Vaccine Deferral was recorded	Current Date
Deferral Reason	Parental decision (NIP002 00)
Deferral Status	Deferred

Notes
No Note

2.2.3. Enter Immunization Data for MMR Given 2 Weeks Prior

Test Step Type: SUT_MANUAL
Patient History from the parent for the latest MMR vaccine that was given 2 weeks prior to the current visit? is entered into the EMR. This is a pre-condition to the attempt to enter the varicella vaccine order.

Test Story

Description

The EHR vendor loads immunization history data for an MMR dose entered 2 weeks prior to the current visit date and an MMR dose that was given too early. These MMR doses serve to seed checking for the condition that it is too early to give a live vaccine in TestCaseGroup: Juana Mariana Vazquez Visit, TestCase: Juana Mariana Vazquez, Enter Orders and Immunizations, TestStep: Attempt to order Varicella Dose.

Comments
No Comments

Pre-condition
The EMR has recorded all of the pediatric demographic data in the record created for Juana Mariana Vazquez. All test steps that are part of the Query the Registry for Juana Mariana test steps are completed, including the vaccination forecasting.

Post-Condition
The immunization history of the MMR that was administered 2 weeks prior to the test date is loaded into the record created for Juana Mariana Vazquez.

Test Objectives

Supporting data for:

Evaluation Criteria

Vaccine from Practice MMR II
Entered BY	Sandra Molina	Y
Ordering Provider	Frank Smith	Y
Entering Organization	Shoreline Pediatrics	Y
Administration Notes (Vaccine Event information source)	Historical information - from parent's written record (NIP001 03)	Y
Date/Time of Start of Administration	14 days prior to the Current Date	Y
Vaccine Administered	measles, mumps and rubella virus vaccine (CVX 03, NDC 0006-4681-00 - MMR II)	Y
Administered Amount (of Vaccine)	0.5	Y
Administered Units (of Measure)	mL	Y
Administering Provider	Sandra Molina	Y
Administered-at Location	400 Shoreline Drive, Stamford Connecticut 06901	Y
Lot Number	0934GG	Y
Substance Expiration Date	12/31/2019	Y
Substance Manufacturer.	Merck Sharp & Dohme Corp (MVX MSD)	Y
Completion Status	Completed (CP)	Y
Route of Administration	Subcutaneous (NCIT C28399, HL70162: SC)	Y
Administration Site	Left Deltoid (HL70163 LD)	Y

Notes
The MMR doses serve to seed checking for the condition that it is too early to give a live vaccine in TestCaseGroup: Juana Mariana Vazquez Visit, TestCase: Juana Mariana Vazquez, Enter Orders and Immunizations, TestStep: Attempt to order Varicella Dose.

2.2.4. Attempt to order Varicella Dose

Test Step Type: SUT_MANUAL
No Description

Test Story

Description
The provider attempts to give a Varicella dose, and is warned that it is too soon to give a live vaccine dose.

Comments
No Comments

Pre-condition
Initial data load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. MMR dose entered at 14 days prior to the current date in TestCaseGroup: Juana Marian Vazquez Visit, TestCase: Juana Mariana Vazquez, Enter Immunization Data for MMR Given 2 Weeks Prior.

Post-Condition
The provider has been issued a warning that it is too soon to give another live virus dose.

Test Objectives

Evaluation Criteria
There should be a warning that the attempt to give a new Varicella Dose is too early - should get warning that 28 days must pass between 2 live virus vaccines if not administered at the same time due to the prior MMR vaccination 14 days earlier.

Notes

If the checking that the dose is too early is handled in the forecast logic rather than the orders interface, this is acceptable to demonstrate the capability.

It can be expressed where it is not part of the recommended forecast and showing it is not 'due' or recommended until a later date.

2.2.5. Order Influenza Vaccine

Test Step Type: SUT_MANUAL
The provider selects to order Influenza Vaccine

Test Story

Description

The physician accesses the record for Juana Mariana Vazquez and:

- Selects order for Influenza vaccine

Comments
This order is a pre-condition to the following two steps related to recording the Influenza Vaccine

Pre-condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR.

Post-Condition
Influenza order entered in patient record.

Test Objectives
Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines.

Evaluation Criteria

EMR records the following order information. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source	New immunization record (NIP001 00)
Value/Text for Vaccine Type	Influenza, seasonal, injectable, preservative free (CVX 140, NDC 58160-0881-41)
Date/Time Vaccine was recorded	Current Date

Notes
No Note

2.2.6. Records Influenza Vaccine administration route with data validation checking

Test Step Type: SUT_MANUAL
The provider records the vaccine administration in the EMR and is prevented from incorrectly documenting vaccine route.

Test Story

Description
The nurse documents administration route for the IM inactivated influenza vaccine as 'intranasal' - Is prevented from documenting "intranasal" for intramuscular inactivated influenza vaccine

Comments
This step covers data quality checking as an informative aspect of vaccine administration

Pre-condition
Order is placed for intramuscular inactivated influenza vaccine.

Post-Condition
The intramuscular, inactivated influenza vaccination route has failed to be recorded as intranasal in the EMR.

Test Objectives

Evaluation Criteria
The EMR prevents the user from entering 'Intranasal' as a route for the the intramuscular ,inactivated influenza vaccine.

Notes
No Note

2.2.7. Record Influenza Vaccine administration

Test Step Type: SUT_MANUAL
The provider documents in the EMR all attributes associated with the new vaccine administration.

Test Story

Description

The nurse administers the inactivated influenza vaccine
- Documents all required information for the vaccine

Comments
No Comments

Pre-condition
Order is placed for inactivated influenza vaccine.

Post-Condition
The inactivated influenza vaccinations is recorded in the EMR.

Test Objectives

Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered. The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size.

Evaluation Criteria

The tester Verifies that there is a choice for VFC stock as she is VFC Eligible. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:.

EMR Records the following vaccine administration information:

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source (Administration Notes)	New immunization record (NIP001 00)
Value/Text for Vaccine Type	Influenza, seasonal, injectable, preservative free (CVX 140, NDC 58160-0881-41)
Date/Time of Start of Administration	Current Date
Vaccine Administered	Influenza, seasonal, injectable, preservative free (CVX 140, NDC 58160-0881-41 FLUARIX)
Administered Amount (of Vaccine)	0.5
Administered Units (of Measure)	mL
Administering Provider	Sandra Molina
Administered-at Location	400 Shoreline Drive, Stamford Connecticut 06901
Lot Number	8L4B3521
Substance Expiration Date	12/31/2019
Substance Manufacturer Name	GlaxoSmithKline (SKB)
Completion Status	Completed (CP)
Route of Administration	Intramuscular (NCIT C28161, HL70162 IM)
Administration Site	Left Deltoid (HL70163 LD)
VFC Eligibility	Yes
Funding Source	Public

Notes
The EMR does not need to specify a 'new immunization', as long as there is a way to indicate that it is a new immunization within the EMR, this is acceptable (e.g. the default interpretation of the data entry is that it is a new immunization and not historical).

2.3. Juana Mariana Vazquez Transmit Immunization Report

Send the Immunization Report to the Immunization Registry (VXU/Z22) for Juana Mariana Vazquez.

Test Story

Description
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report should include vaccines incorrectly recorded in the IIS. The report MAY send the immunizations that the EMR imported from the IIS.

Comments
The Report must include all newly administered vaccines in any order. The report should also include the corrected information where the EMR has different information than the IIS, and may also include the information imported from the IIS.

Pre-condition
The vaccines for the visit have been administered.

Post-Condition
The IIS has received the vaccine information (Z22 message).

Test Objectives

Identify Adverse Event: The EHR or other clinical software system enables capture of structured data regarding adverse events.

Notify Public Health Immunization Registry (IIS) of Update from Adverse Event: The EHR or other clinical software system notifies the public health immunization registry (IIS) of an update due to an adverse event.

Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization.
a. NDC codes, CVX for immunizations

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
Sending information updated in the EMR back to the registry is an advanced function and some registries will not accept updates.

2.3.1. Transmit the immunization report to the Immunization Registry

Test Step Type: SUT_INITIATOR
The EMR send the Immunization Report to the Immunization Registry (VXU/Z22) for updated vaccination information from the visit. This includes all newly administered vaccines and may include historical information updated in the EMR during the visit.

Test Story

Description
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report should include vaccines incorrectly recorded in the IIS. The report MAY send the immunizations that the EMR imported from the IIS.

Comments
The Report must include all newly administered vaccines in any order. the report should also include the corrected information where the EMR has different information than the IIS, and may also include the information imported from the IIS.

Pre-condition
The vaccines for the visit have been administered.

Post-Condition
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission.

Test Objectives

Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries.

Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization.
a. NDC codes, CVX for immunizations

Evaluation Criteria
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content.

Notes
Sending information updated in the EMR back to the registry is an advanced function and some registries will not accept updates.

Message Contents

MSH : Message Header

Location	Data Element	Data	Categorization
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	Test EHR Application
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	X68
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NIST Test Iz Reg
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20180701082240-0500
MSH-9	Message Type
MSH-9.1	Message Code	VXU
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	VXU_V04
MSH-10	Message Control ID	NIST-IZ-001.00
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z22
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	IIPEHRFAC	Presence-Content Indifferent
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code	XX	Presence-Content Indifferent
MSH-22.10	Organization Identifier	100-1	Presence-Content Indifferent
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	IIPIISFAC	Presence-Content Indifferent
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code	XX	Presence-Content Indifferent
MSH-23.10	Organization Identifier	100-2	Presence-Content Indifferent

PID : Patient Identification

Location	Data Element	Data	Categorization
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Vazquez
PID-5.2	Given Name	Juana
PID-5.3	Second and Further Given Names or Initials Thereof	Mariana
PID-5.7	Name Type Code	L
PID-6	Mother's Maiden Name
PID-6.1	Family Name
PID-6.1.1	Surname	Acosta	Value-Test Case Fixed
PID-6.7	Name Type Code	M	Value-Test Case Fixed
PID-7	Date/Time of Birth
PID-7.1	Time	201311011105	Value-Test Case Fixed
PID-8	Administrative Sex	F	Value-Test Case Fixed
PID-10	Race
PID-10.1	Identifier	2106-3	Value-Test Case Fixed
PID-10.2	Text	White	Value-Test Case Fixed
PID-10.3	Name of Coding System	CDCREC	Value-Test Case Fixed
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	4345 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford	Value-Test Case Fixed
PID-11.4	State or Province	CT	Value-Test Case Fixed
PID-11.5	Zip or Postal Code	06903	Value-Test Case Fixed
PID-11.6	Country	USA	Value-Test Case Fixed
PID-11.7	Address Type	L	Value-Test Case Fixed
PID-13[1]	Phone Number - Home
PID-13[1].2	Telecommunication Use Code	PRN	Value-Test Case Fixed
PID-13[1].3	Telecommunication Equipment Type	CP	Value-Test Case Fixed
PID-13[1].4	Email Address
PID-13[1].6	Area/City Code	203	Value-Test Case Fixed
PID-13[1].7	Local Number	5551212	Value-Test Case Fixed
PID-13[2]	Phone Number - Home
PID-13[2].2	Telecommunication Use Code	NET	Value-Test Case Fixed
PID-13[2].3	Telecommunication Equipment Type
PID-13[2].4	Email Address	jmg@gmail.com	Value-Test Case Fixed
PID-13[2].6	Area/City Code
PID-13[2].7	Local Number
PID-22	Ethnic Group
PID-22.1	Identifier	2135-2	Value-Test Case Fixed
PID-22.2	Text	Hispanic or Latino	Value-Test Case Fixed
PID-22.3	Name of Coding System	CDCREC	Value-Test Case Fixed
PID-24	Multiple Birth Indicator
PID-25	Birth Order
PID-29	Patient Death Date and Time
PID-29.1	Time
PID-30	Patient Death Indicator

PD1 : Patient Additional Demographic

Location	Data Element	Data	Categorization
PD1-11	Publicity Code
PD1-11.1	Identifier	02	Value-Test Case Fixed
PD1-11.2	Text	Reminder/Recall - any method	Presence-Content Indifferent
PD1-11.3	Name of Coding System	HL70215	Value-Test Case Fixed
PD1-12	Protection Indicator	N	Value-Test Case Fixed
PD1-13	Protection Indicator Effective Date
PD1-16	Immunization Registry Status	A
PD1-17	Immunization Registry Status Effective Date	20140701	Presence-Content Indifferent
PD1-18	Publicity Code Effective Date	20140701	Presence-Content Indifferent

NK1 : Next of Kin / Associated Parties

Location	Data Element	Data	Categorization
NK1-1	Set ID - NK1	1
NK1-2	Name
NK1-2.1	Family Name
NK1-2.1.1	Surname	Vazquez	Value-Test Case Fixed
NK1-2.2	Given Name	Joanna	Value-Test Case Fixed
NK1-2.3	Second and Further Given Names or Initials Thereof	Merida	Value-Test Case Fixed
NK1-2.7	Name Type Code	L	Value-Test Case Fixed
NK1-3	Relationship
NK1-3.1	Identifier	GRP	Value-Test Case Fixed
NK1-3.2	Text	Grandparent	Value-Test Case Fixed
NK1-3.3	Name of Coding System	HL70063	Value-Test Case Fixed
NK1-4	Address
NK1-4.1	Street Address
NK1-4.1.1	Street or Mailing Address	4345 Standish Way
NK1-4.2	Other Designation
NK1-4.3	City	Stamford	Value-Test Case Fixed
NK1-4.4	State or Province	CT	Value-Test Case Fixed
NK1-4.5	Zip or Postal Code	06901	Value-Test Case Fixed
NK1-4.6	Country
NK1-4.7	Address Type	L
NK1-5[1]	Phone Number
NK1-5[1].2	Telecommunication Use Code	PRN	Value-Test Case Fixed
NK1-5[1].3	Telecommunication Equipment Type	PH	Value-Test Case Fixed
NK1-5[1].4	Email Address
NK1-5[1].6	Area/City Code	203	Value-Test Case Fixed
NK1-5[1].7	Local Number	5551212	Value-Test Case Fixed
NK1-5[2]	Phone Number
NK1-5[2].2	Telecommunication Use Code	NET	Value-Test Case Fixed
NK1-5[2].3	Telecommunication Equipment Type
NK1-5[2].4	Email Address	jmg@gmail.com	Value-Test Case Fixed
NK1-5[2].6	Area/City Code
NK1-5[2].7	Local Number

ORC[*]

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina	Presence-Content Indifferent
ORC-10.3	Given Name	Sandra	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith	Presence-Content Indifferent
ORC-12.3	Given Name	Frank	Presence-Content Indifferent
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP	Presence-Content Indifferent
ORC-17.2	Text	Shoreline Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina	Presence-Content Indifferent
ORC-10.3	Given Name	Sandra	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Ricci
ORC-12.3	Given Name	Gina
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP	Presence-Content Indifferent
ORC-17.2	Text	Shoreline Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina	Presence-Content Indifferent
ORC-10.3	Given Name	Sandra	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith	Presence-Content Indifferent
ORC-12.3	Given Name	Frank	Presence-Content Indifferent
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L	Presence-Content Indifferent
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP	Presence-Content Indifferent
ORC-17.2	Text	Shoreline Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20131101	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	08	Value-Test Case Fixed
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6332FK33
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141214
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20131220	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	45	Value-Test Case Fixed
RXA-5.2	Text	hepatitis B vaccine, unspecified formulation	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6352FK1	Value-Test Case Fixed
RXA-16	Substance Expiration Date
RXA-16.1	Time	20131231	Value-Test Case Fixed
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB	Value-Test Case Fixed
RXA-17.2	Text	GlaxoSmithKline Biologicals SA	Presence-Content Indifferent
RXA-17.3	Name of Coding System	MVX	Value-Test Case Fixed
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP	Value-Test Case Fixed
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140520	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	08	Value-Test Case Fixed
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6352FK24
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150831
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140122	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	107	Value-Test Case Fixed
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D409QS2341
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141130
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140323	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	106	Value-Test Case Fixed
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D409QS2433
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140904
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140522	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	106	Value-Test Case Fixed
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D409QS3255
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150221	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	106	Value-Test Case Fixed
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D409QS249
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150301
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20171120	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	106	Value-Test Case Fixed
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	02	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from other provider	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Casera
RXA-10.3	Given Name	Linda
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D643QS8243	Indifferent
RXA-16	Substance Expiration Date
RXA-16.1	Time	20171201	Indifferent
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC	Indifferent
RXA-17.2	Text	Sanofi Pasteur Inc	Indifferent
RXA-17.3	Name of Coding System	MVX	Indifferent
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP	Value-Test Case Fixed
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140122	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	49	Value-Test Case Fixed
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	7M54K9245
RXA-16	Substance Expiration Date
RXA-16.1	Time	20130324
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140323	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	49	Value-Test Case Fixed
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	7M55K3342
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141030
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140522	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	49	Value-Test Case Fixed
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	7M75K4566
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140523
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141121	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	49	Value-Test Case Fixed
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	7M53K5534
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150222
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140122	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	10	Value-Test Case Fixed
RXA-5.2	Text	poliovirus vaccine, inactivated	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D333PV2431
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141004
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140323	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	10	Value-Test Case Fixed
RXA-5.2	Text	poliovirus vaccine, inactivated	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D333PV4344
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150323
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150221	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	10	Value-Test Case Fixed
RXA-5.2	Text	poliovirus vaccine, inactivated	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	02	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from other provider	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Casera
RXA-10.3	Given Name	Linda
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D335PV9644
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150422
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031	Presence-Content Indifferent
RXA-5	Administered Code
RXA-5.1	Identifier	10	Value-Test Case Fixed
RXA-5.2	Text	poliovirus vaccine, inactivated	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier	00	Value-Test Case Fixed
RXA-18.2	Text	Parental decision	Presence-Content Indifferent
RXA-18.3	Name of Coding System	NIP002	Value-Test Case Fixed
RXA-20	Completion Status	RE	Value-Test Case Fixed
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140122	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	133	Value-Test Case Fixed
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	P243V3281
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140130
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140323	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	133	Value-Test Case Fixed
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	P343V8321
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140330
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140522	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	133	Value-Test Case Fixed
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	P853V2164
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140830
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150111	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	133	Value-Test Case Fixed
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	P853V58532
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150418
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140122	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	119	Value-Test Case Fixed
RXA-5.2	Text	rotavirus, live, monovalent vaccine	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6359RV533
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140215
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140323	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	119	Value-Test Case Fixed
RXA-5.2	Text	rotavirus, live, monovalent vaccine	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6359RV533
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140510
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140925	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	161	Value-Test Case Fixed
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D8043IN8734
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150312
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141029	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	161	Value-Test Case Fixed
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D8043IN8734
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150312
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151002	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	161	Value-Test Case Fixed
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D9334IN9333
RXA-16	Substance Expiration Date
RXA-16.1	Time	20160522
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20161104	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	161	Value-Test Case Fixed
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D9553IN2243
RXA-16	Substance Expiration Date
RXA-16.1	Time	20170430
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20171015	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	140	Value-Test Case Fixed
RXA-5.2	Text	Influenza, seasonal, injectable, preservative Free	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	03	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from parent's written record	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Ricci
RXA-10.3	Given Name	Gina
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	8L4B3423	Indifferent
RXA-16	Substance Expiration Date
RXA-16.1	Time	20171230	Indifferent
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB	Indifferent
RXA-17.2	Text	GlaxoSmithKline	Indifferent
RXA-17.3	Name of Coding System	MVX	Indifferent
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031	Presence-Content Indifferent
RXA-5	Administered Code
RXA-5.1	Identifier	58160-0883-41	Value-Test Case Fixed
RXA-5.2	Text	FLUARIX	Presence-Content Indifferent
RXA-5.3	Name of Coding System	NDC	Value-Test Case Fixed
RXA-6	Administered Amount	0.5	Value-Test Case Fixed
RXA-7	Administered Units
RXA-7.1	Identifier	mL	Value-Test Case Fixed
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM	Value-Test Case Fixed
RXA-9	Administration Notes
RXA-9.1	Identifier	00	Value-Test Case Fixed
RXA-9.2	Text	New immunization record	Value-Test Case Fixed
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina	Presence-Content Indifferent
RXA-10.3	Given Name	Sandra	Presence-Content Indifferent
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	8L4B3521	Value-Test Case Fixed
RXA-16	Substance Expiration Date
RXA-16.1	Time	20191231	Value-Test Case Fixed
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB	Value-Test Case Fixed
RXA-17.2	Text	GlaxoSmithKline	Value-Test Case Fixed
RXA-17.3	Name of Coding System	MVX	Value-Test Case Fixed
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP	Value-Test Case Fixed
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141123	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	83	Value-Test Case Fixed
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6359RT33
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150104
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150523	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	83	Value-Test Case Fixed
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6359RT48
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150911
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140822	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	03	Value-Test Case Fixed
RXA-5.2	Text	measles, mumps, rubella virus vaccine	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	0853CC
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141215
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20171122	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	03	Value-Test Case Fixed
RXA-5.2	Text	measles, mumps, rubella virus vaccine	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	0854FF
RXA-16	Substance Expiration Date
RXA-16.1	Time	20180413
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181015	Presence-Content Indifferent
RXA-5	Administered Code
RXA-5.1	Identifier	03	Value-Test Case Fixed
RXA-5.2	Text	measles, mumps, rubella virus vaccine	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	01	Value-Test Case Fixed
RXA-9.2	Text	historical	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	0934GG
RXA-16	Substance Expiration Date
RXA-16.1	Time	20191231
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151215	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	21	Value-Test Case Fixed
RXA-5.2	Text	varicella virus vaccine	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	2341BB
RXA-16	Substance Expiration Date
RXA-16.1	Time	20161201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data	Categorization
RXR-1	Route
RXR-1.1	Identifier	C28161	Indifferent
RXR-1.2	Text	Intramuscular	Indifferent
RXR-1.3	Name of Coding System	NCIT	Indifferent
RXR-2	Administration Site
RXR-2.1	Identifier	RT	Value-Test Case Fixed
RXR-2.2	Text	Right Thigh	Presence-Content Indifferent
RXR-2.3	Name of Coding System	HL70163	Value-Test Case Fixed

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data	Categorization
RXR-1	Route
RXR-1.1	Identifier	C28161	Indifferent
RXR-1.2	Text	Intramuscular	Indifferent
RXR-1.3	Name of Coding System	NCIT	Indifferent
RXR-2	Administration Site
RXR-2.1	Identifier
RXR-2.2	Text
RXR-2.3	Name of Coding System

RXR : Pharmacy/Treatment Route

Location	Data Element	Data	Categorization
RXR-1	Route
RXR-1.1	Identifier	C28161	Value-Test Case Fixed
RXR-1.2	Text	Intramuscular	Presence-Content Indifferent
RXR-1.3	Name of Coding System	NCIT	Value-Test Case Fixed
RXR-2	Administration Site
RXR-2.1	Identifier
RXR-2.2	Text
RXR-2.3	Name of Coding System

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	31044-1
OBX-3.2	Text	Reaction
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC12
OBX-5.2	Text	fever of >40.5C (105F) within 48 hours of dose
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150221
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	1
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9	Value-Test Case Fixed
OBX-3.2	Text	VIS Publication Date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20140819	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7	Value-Test Case Fixed
OBX-3.2	Text	VIS Presentation Date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20181031	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7	Value-Test Case Fixed
OBX-3.2	Text	vaccine fund pgm elig cat	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V02	Value-Test Case Fixed
OBX-5.2	Text	VFC eligible-Medicaid/Medicaid Managed Care	Presence-Content Indifferent
OBX-5.3	Name of Coding System	HL70064	Value-Test Case Fixed
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30963-3
OBX-3.2	Text	Vaccine funding source
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC50
OBX-5.2	Text	Public
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

Test Data Specification

Patient Information

Element	Data
Patient Name	Juana Mariana Vazquez
Mother's Maiden Name	Maria Acosta
ID Number	123456 987633
Date/Time of Birth	11/01/2013 11:05
Administrative Sex	Female
Patient Address	4345 Standish Way Stamford CT 06903 USA
Local Number	(203)555-1212
Email	jmg@gmail.com
Race	White
Ethnic Group	Hispanic or Latino
Multiple Birth Indicator	No
Birth Order

Immunization Registry Information

Element	Data
Immunization Registry Status	Active
Immunization Registry Status Effective Date	07/01/2014
Publicity Code	Reminder/Recall - any method
Publicity Code Effective Date	07/01/2014
Protection Indicator	No
Protection Indicator Effective Date

Guardian or Responsible Party

Element	Data
Name	Joanna Merida Vazquez
Relationship	Grandparent
Address	4345 Standish Way Stamford CT 06901
Phone Number	(203)555-1212
Phone Number

Vaccine Administration Information[*]

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration	11/01/2013
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6332FK33
Substance Expiration Date	12/14/2014
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, unspecified formulation
Date/Time Start of Administration	12/20/2013
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6352FK1
Substance Expiration Date	12/31/2013
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration	05/20/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6352FK24
Substance Expiration Date	08/31/2015
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Date/Time Start of Administration	01/22/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS2341
Substance Expiration Date	11/30/2014
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	03/23/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS2433
Substance Expiration Date	09/04/2014
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	05/22/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS3255
Substance Expiration Date	12/01/2014
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	02/21/2015
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS249
Substance Expiration Date	03/01/2015
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	11/20/2017
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from other provider
Administering Provider	Linda Casera
Substance Lot Number	D643QS8243
Substance Expiration Date	12/01/2017
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	J Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	01/22/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M54K9245
Substance Expiration Date	03/24/2013
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	03/23/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M55K3342
Substance Expiration Date	10/30/2014
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	05/22/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M75K4566
Substance Expiration Date	05/23/2014
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	11/21/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M53K5534
Substance Expiration Date	02/22/2015
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	01/22/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D333PV2431
Substance Expiration Date	10/04/2014
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	03/23/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D333PV4344
Substance Expiration Date	03/23/2015
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	02/21/2015
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from other provider
Administering Provider	Linda Casera
Substance Lot Number	D335PV9644
Substance Expiration Date	04/22/2015
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	J Rodriguez

Element	Data
Reaction	fever of >40.5C (105F) within 48 hours of dose

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	10/31/2018
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason	Parental decision
Completion Status	Refused
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	01/22/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P243V3281
Substance Expiration Date	01/30/2014
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	03/23/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P343V8321
Substance Expiration Date	03/30/2014
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	05/22/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P853V2164
Substance Expiration Date	08/30/2014
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	01/11/2015
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P853V58532
Substance Expiration Date	04/18/2015
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	rotavirus, live, monovalent vaccine
Date/Time Start of Administration	01/22/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RV533
Substance Expiration Date	02/15/2014
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	rotavirus, live, monovalent vaccine
Date/Time Start of Administration	03/23/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RV533
Substance Expiration Date	05/10/2014
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	09/25/2014
Administered Amount	0.25
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D8043IN8734
Substance Expiration Date	03/12/2015
Substance Manufacturer Name	Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	10/29/2014
Administered Amount	0.25
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D8043IN8734
Substance Expiration Date	03/12/2015
Substance Manufacturer Name	Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	10/02/2015
Administered Amount	.25
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D9334IN9333
Substance Expiration Date	05/22/2016
Substance Manufacturer Name	Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	11/04/2016
Administered Amount	0.25
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D9553IN2243
Substance Expiration Date	04/30/2017
Substance Manufacturer Name	Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, seasonal, injectable, preservative Free
Date/Time Start of Administration	10/15/2017
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from parent's written record
Administering Provider	Gina Ricci
Substance Lot Number	8L4B3423
Substance Expiration Date	12/30/2017
Substance Manufacturer Name	GlaxoSmithKline
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Gina Ricci

Vaccine Administration Information

Element	Data
Administered Vaccine	FLUARIX
Date/Time Start of Administration	10/31/2018
Administered Amount	0.5
Administered Units
Administration Notes	New immunization record
Administering Provider	Sandra Molina
Substance Lot Number	8L4B3521
Substance Expiration Date	12/31/2019
Substance Manufacturer Name	GlaxoSmithKline
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
VIS Publication Date	08/19/2014
VIS Presentation Date	10/31/2018
vaccine fund pgm elig cat	VFC eligible-Medicaid/Medicaid Managed Care
Vaccine funding source	Public

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Date/Time Start of Administration	11/23/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RT33
Substance Expiration Date	01/04/2015
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Date/Time Start of Administration	05/23/2015
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RT48
Substance Expiration Date	09/11/2015
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	measles, mumps, rubella virus vaccine
Date/Time Start of Administration	08/22/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	Sandra Molina
Substance Lot Number	0853CC
Substance Expiration Date	12/15/2014
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Thigh
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	measles, mumps, rubella virus vaccine
Date/Time Start of Administration	11/22/2017
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	0854FF
Substance Expiration Date	04/13/2018
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	measles, mumps, rubella virus vaccine
Date/Time Start of Administration	10/15/2018
Administered Amount	0.5
Administered Units
Administration Notes	historical
Administering Provider	Sandra Molina
Substance Lot Number	0934GG
Substance Expiration Date	12/31/2019
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	varicella virus vaccine
Date/Time Start of Administration	12/15/2015
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	2341BB
Substance Expiration Date	12/01/2016
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Right Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

2.3.2. Receive ACK Z23 from Immunization Registry

Test Step Type: TA_RESPONDER
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message.

Test Story

Description
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message.

Comments
No Comments

Pre-condition
A VXU message is generated by the EHR.

Post-Condition
The ACK Z23 is received by the EHR.

Test Objectives
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries.

Evaluation Criteria
The acknowledgement message is consumed by the system responsible for the content of the administration message without error. This is not typically part of the user interface, so this may be demonstrated through back-end evidence.

Notes
Important note regarding the MSH-10 and MSA-2: The NIST acknowledgment message is predefined and is based on the VXU message. Most systems will automatically create the message control Identifier and may require it for importing, linking, and processing the ACK message. The NIST ACK test message can be modified such that MSA-2 matches MSH-10 of the VXU message generated by the system-under test.

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	NISTIISAPP
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	NISTIISFAC
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	NISTEHRAPP
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NISTEHRFAC
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20180224073734.034-0500
MSH-9	Message Type
MSH-9.1	Message Code	ACK
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	ACK
MSH-10	Message Control ID	NIST-IZ-AD-1.2_Receive_ACK_Z23
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z23
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	NISTIISFAC
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	NISTEHRFAC
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	NIST-IZ-AD-1.1_Send_V04_Z22

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

2.3.3. Record an adverse reaction

Test Step Type: SUT_MANUAL
The Provider records in the EMR an adverse reaction of rash within 14 days of dose.

Test Story

Description
Following the vaccine administration, the mother reports that the patient had a rash within 14 days of dose.

Comments
No Comments

Pre-condition
The vaccinations for the visit have been administered.

Post-Condition
The adverse reaction to the Influenza vaccination of rash within 14 days of dose is recorded in the EMR.

Test Objectives

Identify Adverse Event: The EHR or other clinical software system enables capture of structured data regarding adverse events.

Support for:

Notify Public Health Immunization Registry (IIS) of Update from Adverse Event: The EHR or other clinical software system notifies the public health immunization registry (IIS) of an update due to an adverse event.

Evaluation Criteria

Verify that vendor can record the adverse reaction to the Influenza vaccination of rash within 14 days of dose correctly and without omission (VXC14). The coded value is not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions.

If the vendor is unable to record the concept (VXC14) using the CDCPHINVS coding system to convey this reaction to the registry, the vendor may specify the reaction using SNOMED-CT or Narrative Text. This should be recorded as passing, but with a notable exception documented.

Notes
Adverse Reactions may be documented with SNOMED-CT or as a narrative note. These two approaches may be considered passing with notable exception. The approach that is used instead of the value set PHVS_VaccinationReaction_IIS 2.16.840.1.114222.4.11.3289 should be documented in the tester notes.

2.3.4. Transmit the updated vaccination report with adverse reaction to the registry

Test Step Type: SUT_INITIATOR
The EMR generates a Z22 Send Unsolicited Immunization Update Using a VXU correctly and without omission according to supplied test data.

Test Story

Description
The adverse reaction to the Influenza vaccination of rash within 14 days of dose is reported to the Immunization Registry using a Z22/VXU message.

Comments
No Comments

Pre-condition
An adverse reaction to the Influenza vaccination of rash within 14 days of dose is recorded in the EMR.

Post-Condition
The adverse reaction has been transmitted to the IIS.

Test Objectives

Identify Adverse Event: The EHR or other clinical software system enables capture of structured data regarding adverse events.

Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization.
a. NDC codes, CVX for immunizations

Evaluation Criteria
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content.

Notes
The tester verifies that the message includes 'U' in RXA 21 for the Influenza vaccine.

Message Contents

MSH : Message Header

Location	Data Element	Data	Categorization
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	Test EHR Application
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	X68
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NIST Test Iz Reg
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20180701082240-0500
MSH-9	Message Type
MSH-9.1	Message Code	VXU
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	VXU_V04
MSH-10	Message Control ID	NIST-IZ-001.00
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z22
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	IIPEHRFAC	Presence-Content Indifferent
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code	XX	Presence-Content Indifferent
MSH-22.10	Organization Identifier	100-1	Presence-Content Indifferent
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	IIPIISFAC	Presence-Content Indifferent
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code	XX	Presence-Content Indifferent
MSH-23.10	Organization Identifier	100-2	Presence-Content Indifferent

PID : Patient Identification

Location	Data Element	Data	Categorization
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Vazquez
PID-5.2	Given Name	Juana
PID-5.3	Second and Further Given Names or Initials Thereof	Mariana
PID-5.7	Name Type Code	L
PID-6	Mother's Maiden Name
PID-6.1	Family Name
PID-6.1.1	Surname	Acosta	Value-Test Case Fixed
PID-6.7	Name Type Code	M	Value-Test Case Fixed
PID-7	Date/Time of Birth
PID-7.1	Time	201311011105	Value-Test Case Fixed
PID-8	Administrative Sex	F	Value-Test Case Fixed
PID-10	Race
PID-10.1	Identifier	2106-3	Value-Test Case Fixed
PID-10.2	Text	White	Value-Test Case Fixed
PID-10.3	Name of Coding System	CDCREC	Value-Test Case Fixed
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	4345 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford	Value-Test Case Fixed
PID-11.4	State or Province	CT	Value-Test Case Fixed
PID-11.5	Zip or Postal Code	06903	Value-Test Case Fixed
PID-11.6	Country	USA	Value-Test Case Fixed
PID-11.7	Address Type	L	Value-Test Case Fixed
PID-13[1]	Phone Number - Home
PID-13[1].2	Telecommunication Use Code	PRN	Value-Test Case Fixed
PID-13[1].3	Telecommunication Equipment Type	CP	Value-Test Case Fixed
PID-13[1].4	Email Address
PID-13[1].6	Area/City Code	203	Value-Test Case Fixed
PID-13[1].7	Local Number	5551212	Value-Test Case Fixed
PID-13[2]	Phone Number - Home
PID-13[2].2	Telecommunication Use Code	NET	Value-Test Case Fixed
PID-13[2].3	Telecommunication Equipment Type
PID-13[2].4	Email Address	jmg@gmail.com	Value-Test Case Fixed
PID-13[2].6	Area/City Code
PID-13[2].7	Local Number
PID-22	Ethnic Group
PID-22.1	Identifier	2135-2	Value-Test Case Fixed
PID-22.2	Text	Hispanic or Latino	Value-Test Case Fixed
PID-22.3	Name of Coding System	CDCREC	Value-Test Case Fixed
PID-24	Multiple Birth Indicator
PID-25	Birth Order
PID-29	Patient Death Date and Time
PID-29.1	Time
PID-30	Patient Death Indicator

PD1 : Patient Additional Demographic

Location	Data Element	Data	Categorization
PD1-11	Publicity Code
PD1-11.1	Identifier	02	Value-Test Case Fixed
PD1-11.2	Text	Reminder/Recall - any method	Presence-Content Indifferent
PD1-11.3	Name of Coding System	HL70215	Value-Test Case Fixed
PD1-12	Protection Indicator	N	Value-Test Case Fixed
PD1-13	Protection Indicator Effective Date
PD1-16	Immunization Registry Status	A
PD1-17	Immunization Registry Status Effective Date	20140701	Presence-Content Indifferent
PD1-18	Publicity Code Effective Date	20140701	Presence-Content Indifferent

NK1 : Next of Kin / Associated Parties

Location	Data Element	Data	Categorization
NK1-1	Set ID - NK1	1
NK1-2	Name
NK1-2.1	Family Name
NK1-2.1.1	Surname	Vazquez	Value-Test Case Fixed
NK1-2.2	Given Name	Joanna	Value-Test Case Fixed
NK1-2.3	Second and Further Given Names or Initials Thereof	Merida	Value-Test Case Fixed
NK1-2.7	Name Type Code	L	Value-Test Case Fixed
NK1-3	Relationship
NK1-3.1	Identifier	GRP	Value-Test Case Fixed
NK1-3.2	Text	Grandparent	Value-Test Case Fixed
NK1-3.3	Name of Coding System	HL70063	Value-Test Case Fixed
NK1-4	Address
NK1-4.1	Street Address
NK1-4.1.1	Street or Mailing Address	4345 Standish Way
NK1-4.2	Other Designation
NK1-4.3	City	Stamford	Value-Test Case Fixed
NK1-4.4	State or Province	CT	Value-Test Case Fixed
NK1-4.5	Zip or Postal Code	06901	Value-Test Case Fixed
NK1-4.6	Country
NK1-4.7	Address Type	L
NK1-5[1]	Phone Number
NK1-5[1].2	Telecommunication Use Code	PRN	Value-Test Case Fixed
NK1-5[1].3	Telecommunication Equipment Type	PH	Value-Test Case Fixed
NK1-5[1].4	Email Address
NK1-5[1].6	Area/City Code	203	Value-Test Case Fixed
NK1-5[1].7	Local Number	5551212	Value-Test Case Fixed
NK1-5[2]	Phone Number
NK1-5[2].2	Telecommunication Use Code	NET
NK1-5[2].3	Telecommunication Equipment Type
NK1-5[2].4	Email Address	jmg@gmail.com
NK1-5[2].6	Area/City Code
NK1-5[2].7	Local Number

ORC[*]

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Sirtis	Presence-Content Indifferent
ORC-10.3	Given Name	Lisa	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Carter
ORC-12.3	Given Name	Jane
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SH	Presence-Content Indifferent
ORC-17.2	Text	Shoreline Hospital	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina	Presence-Content Indifferent
ORC-10.3	Given Name	Sandra	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith	Presence-Content Indifferent
ORC-12.3	Given Name	Frank	Presence-Content Indifferent
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP	Presence-Content Indifferent
ORC-17.2	Text	Shoreline Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	F
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina	Presence-Content Indifferent
ORC-10.3	Given Name	Sandra	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Ricci
ORC-12.3	Given Name	Gina
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP	Presence-Content Indifferent
ORC-17.2	Text	Shoreline Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina	Presence-Content Indifferent
ORC-10.3	Given Name	Sandra	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith	Presence-Content Indifferent
ORC-12.3	Given Name	Frank	Presence-Content Indifferent
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L	Presence-Content Indifferent
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP	Presence-Content Indifferent
ORC-17.2	Text	Shoreline Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez
ORC-10.3	Given Name	J
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Herrera
ORC-12.3	Given Name	Carlos
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20131101	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	08	Value-Test Case Fixed
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6332FK33
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141214
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20131220	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	45	Value-Test Case Fixed
RXA-5.2	Text	hepatitis B vaccine, unspecified formulation	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6352FK1	Indifferent
RXA-16	Substance Expiration Date
RXA-16.1	Time	20131231	Indifferent
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB	Indifferent
RXA-17.2	Text	GlaxoSmithKline Biologicals SA	Indifferent
RXA-17.3	Name of Coding System	MVX	Indifferent
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP	Value-Test Case Fixed
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140520	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	08	Value-Test Case Fixed
RXA-5.2	Text	hepatitis B vaccine, pediatric or pediatric/adolescent dosage	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6352FK24
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150831
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140122	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	107	Value-Test Case Fixed
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D409QS2341
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141130
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140323	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	106	Value-Test Case Fixed
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D409QS2433
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140904
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140522	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	106	Value-Test Case Fixed
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D409QS3255
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150221	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	106	Value-Test Case Fixed
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D409QS249
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150301
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20171120	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	106	Value-Test Case Fixed
RXA-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	02	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from other provider	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Casera
RXA-10.3	Given Name	Linda
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D643QS8243	Indifferent
RXA-16	Substance Expiration Date
RXA-16.1	Time	20171201	Indifferent
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC	Indifferent
RXA-17.2	Text	Sanofi Pasteur Inc	Indifferent
RXA-17.3	Name of Coding System	MVX	Indifferent
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP	Value-Test Case Fixed
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140122	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	49	Value-Test Case Fixed
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	7M54K9245
RXA-16	Substance Expiration Date
RXA-16.1	Time	20130324
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140323	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	49	Value-Test Case Fixed
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	7M55K3342
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141030
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140522	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	49	Value-Test Case Fixed
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	7M75K4566
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140523
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141121	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	49	Value-Test Case Fixed
RXA-5.2	Text	Haemophilus influenzae type b vaccine, PRP-OMP conjugate	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	7M53K5534
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150222
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140122	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	10	Value-Test Case Fixed
RXA-5.2	Text	poliovirus vaccine, inactivated	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D333PV2431
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141004
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140323	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	10	Value-Test Case Fixed
RXA-5.2	Text	poliovirus vaccine, inactivated	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D333PV4344
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150323
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150221	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	10	Value-Test Case Fixed
RXA-5.2	Text	poliovirus vaccine, inactivated	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	02	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from other provider	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Casera
RXA-10.3	Given Name	Linda
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D335PV9644
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150422
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031	Presence-Content Indifferent
RXA-5	Administered Code
RXA-5.1	Identifier	10	Value-Test Case Fixed
RXA-5.2	Text	poliovirus vaccine, inactivated	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier	00	Value-Test Case Fixed
RXA-18.2	Text	Parental decision	Presence-Content Indifferent
RXA-18.3	Name of Coding System	NIP002	Value-Test Case Fixed
RXA-20	Completion Status	RE	Value-Test Case Fixed
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140122	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	133	Value-Test Case Fixed
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	P243V3281
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140130
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140323	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	133	Value-Test Case Fixed
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	P343V8321
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140330
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140522	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	133	Value-Test Case Fixed
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	P853V2164
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140830
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150111	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	133	Value-Test Case Fixed
RXA-5.2	Text	pneumococcal conjugate vaccine, 13 valent	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	P853V58532
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150418
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140122	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	119	Value-Test Case Fixed
RXA-5.2	Text	rotavirus, live, monovalent vaccine	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6359RV533
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140215
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140323	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	119	Value-Test Case Fixed
RXA-5.2	Text	rotavirus, live, monovalent vaccine	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6359RV533
RXA-16	Substance Expiration Date
RXA-16.1	Time	20140510
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140925	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	161	Value-Test Case Fixed
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D8043IN8734
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150312
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141029	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	161	Value-Test Case Fixed
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D8043IN8734
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150312
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151002	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	161	Value-Test Case Fixed
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D9334IN9333
RXA-16	Substance Expiration Date
RXA-16.1	Time	20160522
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20161104	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	161	Value-Test Case Fixed
RXA-5.2	Text	Influenza, injectable,quadrivalent, preservative free, pediatric	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D9553IN2243
RXA-16	Substance Expiration Date
RXA-16.1	Time	20170430
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20171015	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	140	Value-Test Case Fixed
RXA-5.2	Text	Influenza, seasonal, injectable, preservative Free	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	03	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from parent's written record	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Ricci
RXA-10.3	Given Name	Gina
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	8L4B3423	Indifferent
RXA-16	Substance Expiration Date
RXA-16.1	Time	20171230	Indifferent
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB	Indifferent
RXA-17.2	Text	GlaxoSmithKline	Indifferent
RXA-17.3	Name of Coding System	MVX	Indifferent
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031	Presence-Content Indifferent
RXA-5	Administered Code
RXA-5.1	Identifier	58160-0883-41	Value-Test Case Fixed
RXA-5.2	Text	FLUARIX	Presence-Content Indifferent
RXA-5.3	Name of Coding System	NDC	Value-Test Case Fixed
RXA-6	Administered Amount	0.5	Value-Test Case Fixed
RXA-7	Administered Units
RXA-7.1	Identifier	mL	Value-Test Case Fixed
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM	Value-Test Case Fixed
RXA-9	Administration Notes
RXA-9.1	Identifier	00	Value-Test Case Fixed
RXA-9.2	Text	New immunization record	Value-Test Case Fixed
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina	Presence-Content Indifferent
RXA-10.3	Given Name	Sandra	Presence-Content Indifferent
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	8L4B3521	Value-Test Case Fixed
RXA-16	Substance Expiration Date
RXA-16.1	Time	20191231	Value-Test Case Fixed
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB	Value-Test Case Fixed
RXA-17.2	Text	GlaxoSmithKline	Presence-Content Indifferent
RXA-17.3	Name of Coding System	MVX	Value-Test Case Fixed
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP	Value-Test Case Fixed
RXA-21	Action Code - RXA	U	Value-Test Case Fixed

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20141123	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	83	Value-Test Case Fixed
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6359RT33
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150104
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20150523	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	83	Value-Test Case Fixed
RXA-5.2	Text	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6359RT48
RXA-16	Substance Expiration Date
RXA-16.1	Time	20150911
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20140822	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	03	Value-Test Case Fixed
RXA-5.2	Text	measles, mumps, rubella virus vaccine	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	0853CC
RXA-16	Substance Expiration Date
RXA-16.1	Time	20141215
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20171122	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	03	Value-Test Case Fixed
RXA-5.2	Text	measles, mumps, rubella virus vaccine	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	0854FF
RXA-16	Substance Expiration Date
RXA-16.1	Time	20180413
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181015	Presence-Content Indifferent
RXA-5	Administered Code
RXA-5.1	Identifier	03	Value-Test Case Fixed
RXA-5.2	Text	measles, mumps, rubella virus vaccine	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	01	Value-Test Case Fixed
RXA-9.2	Text	historical	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	0934GG
RXA-16	Substance Expiration Date
RXA-16.1	Time	20191231
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp \T\ Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20151215	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	21	Value-Test Case Fixed
RXA-5.2	Text	varicella virus vaccine	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text	Historical information - from public agency	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	2341BB
RXA-16	Substance Expiration Date
RXA-16.1	Time	20161201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data	Categorization
RXR-1	Route
RXR-1.1	Identifier	C28161	Indifferent
RXR-1.2	Text	Intramuscular	Indifferent
RXR-1.3	Name of Coding System	NCIT	Indifferent
RXR-2	Administration Site
RXR-2.1	Identifier	RT	Indifferent
RXR-2.2	Text	Right Thigh	Indifferent
RXR-2.3	Name of Coding System	HL70163	Indifferent

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data	Categorization
RXR-1	Route
RXR-1.1	Identifier	C28161	Indifferent
RXR-1.2	Text	Intramuscular	Indifferent
RXR-1.3	Name of Coding System	NCIT	Indifferent
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data	Categorization
RXR-1	Route
RXR-1.1	Identifier	C28161	Value-Test Case Fixed
RXR-1.2	Text	Intramuscular	Presence-Content Indifferent
RXR-1.3	Name of Coding System	NCIT	Value-Test Case Fixed
RXR-2	Administration Site
RXR-2.1	Identifier	LD	Value-Test Case Fixed
RXR-2.2	Text	Left Deltoid	Presence-Content Indifferent
RXR-2.3	Name of Coding System	HL70163	Value-Test Case Fixed

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RD
RXR-2.2	Text	Right Deltoid
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	31044-1
OBX-3.2	Text	Reaction
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC12
OBX-5.2	Text	fever of >40.5C (105F) within 48 hours of dose
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20150221
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	1
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9	Value-Test Case Fixed
OBX-3.2	Text	VIS Publication Date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20140819	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7	Value-Test Case Fixed
OBX-3.2	Text	VIS Presentation Date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20181031	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7	Value-Test Case Fixed
OBX-3.2	Text	vaccine fund pgm elig cat	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V02	Value-Test Case Fixed
OBX-5.2	Text	VFC eligible-Medicaid/Medicaid Managed Care	Presence-Content Indifferent
OBX-5.3	Name of Coding System	HL70064	Value-Test Case Fixed
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30963-3
OBX-3.2	Text	Vaccine funding source
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC50
OBX-5.2	Text	Public
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	5
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	31044-1	Value-Test Case Fixed
OBX-3.2	Text	Reaction	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC14
OBX-5.2	Text	Rash within 14 days of dose
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

Test Data Specification

Patient Information

Element	Data
Patient Name	Juana Mariana Vazquez
Mother's Maiden Name	Maria Acosta
ID Number	123456 987633
Date/Time of Birth	11/01/2013 11:05
Administrative Sex	Female
Patient Address	4345 Standish Way Stamford CT 06903 USA
Local Number	(203)555-1212
Email	jmg@gmail.com
Race	White
Ethnic Group	Hispanic or Latino
Multiple Birth Indicator	No
Birth Order

Immunization Registry Information

Element	Data
Immunization Registry Status	Active
Immunization Registry Status Effective Date	07/01/2014
Publicity Code	Reminder/Recall - any method
Publicity Code Effective Date	07/01/2014
Protection Indicator	No
Protection Indicator Effective Date

Guardian or Responsible Party

Element	Data
Name	Joanna Merida Vazquez
Relationship	Grandparent
Address	4345 Standish Way Stamford CT 06901
Phone Number	(203)555-1212
Phone Number

Vaccine Administration Information[*]

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration	11/01/2013
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6332FK33
Substance Expiration Date	12/14/2014
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Shoreline Hospital
Entered By	Lisa Sirtis
Ordered By	Jane Carter

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, unspecified formulation
Date/Time Start of Administration	12/20/2013
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6352FK1
Substance Expiration Date	12/31/2013
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration	05/20/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6352FK24
Substance Expiration Date	08/31/2015
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Date/Time Start of Administration	01/22/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS2341
Substance Expiration Date	11/30/2014
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	03/23/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS2433
Substance Expiration Date	09/04/2014
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	05/22/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS3255
Substance Expiration Date	12/01/2014
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	02/21/2015
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D409QS249
Substance Expiration Date	03/01/2015
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration	11/20/2017
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from other provider
Administering Provider	Linda Casera
Substance Lot Number	D643QS8243
Substance Expiration Date	12/01/2017
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	J Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	01/22/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M54K9245
Substance Expiration Date	03/24/2013
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	03/23/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M55K3342
Substance Expiration Date	10/30/2014
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	05/22/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M75K4566
Substance Expiration Date	05/23/2014
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration	11/21/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	7M53K5534
Substance Expiration Date	02/22/2015
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	01/22/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D333PV2431
Substance Expiration Date	10/04/2014
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	03/23/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D333PV4344
Substance Expiration Date	03/23/2015
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	02/21/2015
Administered Amount	999
Administered Units
Administration Notes	Historical information - from other provider
Administering Provider	Linda Casera
Substance Lot Number	D335PV9644
Substance Expiration Date	04/22/2015
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	J Rodriguez

Element	Data
Reaction	fever of >40.5C (105F) within 48 hours of dose

Vaccine Administration Information

Element	Data
Administered Vaccine	poliovirus vaccine, inactivated
Date/Time Start of Administration	10/31/2018
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason	Parental decision
Completion Status	Refused
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	01/22/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P243V3281
Substance Expiration Date	01/30/2014
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	03/23/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P343V8321
Substance Expiration Date	03/30/2014
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	05/22/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P853V2164
Substance Expiration Date	08/30/2014
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration	01/11/2015
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	P853V58532
Substance Expiration Date	04/18/2015
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	rotavirus, live, monovalent vaccine
Date/Time Start of Administration	01/22/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RV533
Substance Expiration Date	02/15/2014
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	rotavirus, live, monovalent vaccine
Date/Time Start of Administration	03/23/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RV533
Substance Expiration Date	05/10/2014
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	F Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	09/25/2014
Administered Amount	0.25
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D8043IN8734
Substance Expiration Date	03/12/2015
Substance Manufacturer Name	Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	10/29/2014
Administered Amount	0.25
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D8043IN8734
Substance Expiration Date	03/12/2015
Substance Manufacturer Name	Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	10/02/2015
Administered Amount	.25
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D9334IN9333
Substance Expiration Date	05/22/2016
Substance Manufacturer Name	Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration	11/04/2016
Administered Amount	0.25
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	D9553IN2243
Substance Expiration Date	04/30/2017
Substance Manufacturer Name	Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza, seasonal, injectable, preservative Free
Date/Time Start of Administration	10/15/2017
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from parent's written record
Administering Provider	Gina Ricci
Substance Lot Number	8L4B3423
Substance Expiration Date	12/30/2017
Substance Manufacturer Name	GlaxoSmithKline
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Gina Ricci

Vaccine Administration Information

Element	Data
Administered Vaccine	FLUARIX
Date/Time Start of Administration	10/31/2018
Administered Amount	0.5
Administered Units
Administration Notes	New immunization record
Administering Provider	Sandra Molina
Substance Lot Number	8L4B3521
Substance Expiration Date	12/31/2019
Substance Manufacturer Name	GlaxoSmithKline
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Update
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
VIS Publication Date	08/19/2014
VIS Presentation Date	10/31/2018
vaccine fund pgm elig cat	VFC eligible-Medicaid/Medicaid Managed Care
Vaccine funding source	Public
Reaction	Rash within 14 days of dose

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Date/Time Start of Administration	11/23/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RT33
Substance Expiration Date	01/04/2015
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Date/Time Start of Administration	05/23/2015
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	6359RT48
Substance Expiration Date	09/11/2015
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	measles, mumps, rubella virus vaccine
Date/Time Start of Administration	08/22/2014
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	Sandra Molina
Substance Lot Number	0853CC
Substance Expiration Date	12/15/2014
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Thigh
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	measles, mumps, rubella virus vaccine
Date/Time Start of Administration	11/22/2017
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	0854FF
Substance Expiration Date	04/13/2018
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

Vaccine Administration Information

Element	Data
Administered Vaccine	measles, mumps, rubella virus vaccine
Date/Time Start of Administration	10/15/2018
Administered Amount	999
Administered Units
Administration Notes	historical
Administering Provider	Sandra Molina
Substance Lot Number	0934GG
Substance Expiration Date	12/31/2019
Substance Manufacturer Name	Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Vaccine Administration Information

Element	Data
Administered Vaccine	varicella virus vaccine
Date/Time Start of Administration	12/15/2015
Administered Amount	0.5
Administered Units
Administration Notes	Historical information - from public agency
Administering Provider	J Martinez
Substance Lot Number	2341BB
Substance Expiration Date	12/01/2016
Substance Manufacturer Name	Merck Sharp and Dohme Corp
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Right Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J Martinez
Ordered By	Carlos Herrera

2.3.5. Receive ACK Z23 from Immunization Registry for Updated Transmission

Test Step Type: TA_RESPONDER
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message.

Test Story

Description
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message.

Comments
No Comments

Pre-condition
A VXU message is generated by the EHR.

Post-Condition
The ACK Z23 is received by the EHR.

Test Objectives
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries.

Evaluation Criteria
The acknowledgement message is consumed by the system responsible for the content of the administration message without error. This is not typically part of the user interface, so this may be demonstrated through back-end evidence.

Notes
Important note regarding the MSH-10 and MSA-2: The NIST acknowledgment message is predefined and is based on the VXU message. Most systems will automatically create the message control Identifier and may require it for importing, linking, and processing the ACK message. The NIST ACK test message can be modified such that MSA-2 matches MSH-10 of the VXU message generated by the system-under test.

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	NISTIISAPP
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	NISTIISFAC
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	NISTEHRAPP
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NISTEHRFAC
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20180224073734.034-0500
MSH-9	Message Type
MSH-9.1	Message Code	ACK
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	ACK
MSH-10	Message Control ID	NIST-IZ-AD-1.2_Receive_ACK_Z23
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z23
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	NISTIISFAC
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	NISTEHRFAC
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	NIST-IZ-AD-1.1_Send_V04_Z22

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

2.4. Juana Mariana Vazquez Display Immunization Report

Produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Test Story

Description
Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Comments
No Comments

Pre-condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered.

Post-Condition
The patient/parent has been provided a patient immunization history report.

Test Objectives
Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. Produce Immunization Forecast Report: The EHR or other clinical software system creates a list of immunizations to be administered within a specified time frame.

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
No Note

2.4.1. Produce an immunization report for Juana Mariana Vazquez including all history

Test Step Type: SUT_MANUAL
The EMR is used to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.).

Test Story

Description
Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Comments
No Comments

Pre-condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered.

Post-Condition
The patient/parent has been provided a patient immunization history report.

Test Objectives

Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers.

Produce Immunization Forecast Report: The EHR or other clinical software system creates a list of immunizations to be administered within a specified time frame.

Evaluation Criteria

The following patient demographics are displayed

Patient Identifier Number: Vendor Assigned

Patient Identifier Type Code: Vendor Assigned

Patient Name: Juana Mariana Vazquez

Date/Time of Birth: 11/01/2013 11:05am

Sex: Female

Patient Address: 4345 Standish Way, Stamford, CT, 06903

Multiple Birth: N

Birth Order: NA

The following Vaccination History is displayed:

Vaccine Group: Hep B Peds NOS

Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)

ENGERIX-B (NDC 58160-0820-11)"

Date Administered: 11/01/2013

Additional Observations: None

Dose #: 1

Doses in Series: 3

Valid Dose: Y

Ordering Provider: Jane Carter

Entered By: Lisa Sirtis

Entering Organization: Shoreline Hospital

Administered Amt: .05 mL

Administering Provider: Jane Carter

Administered at Location: 325 Shoreline Drive,

Stamford Connecticut 06901

Lot#: 6332FK33

Exp Date: 12/14/2013

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: Hep B Peds NOS

Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)

ENGERIX-B (NDC 58160-0820-11)"

Date Administered: 12/20/2013

Additional Observations: None

Dose #: 2

Doses in Series: 3

Valid Dose: Y

Ordering Provider: Frank Smith

Entered By: Sandra Molina

Entering Organization: Shoreline Pediatrics

Administered Amt: .05 mL

Administering Provider: Sandra Molina

Administered at Location: 400 Shoreline Drive,

Stamford Connecticut 06901

Lot#: 6352FK1

Exp Date: 12/31/2013

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: Hep B Peds NOS

Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)

ENGERIX-B (NDC 58160-0820-11)"

Date Administered: 05/20/2014

Additional Observations: None

Dose #: 3

Doses in Series: 3

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: Sandra Molina

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 6352FK24

Exp Date: 8/31/2015

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified

Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)

DAPTACEL (NDC 49281-0286-01)"

Date Administered: 1/22/2014

Additional Observations: None

Dose #: 1

Doses in Series: 5

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D409QS2341

Exp Date: 11/30/2014

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified

Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)

DAPTACEL (NDC 49281-0286-01)

Date Administered: 3/23/2014

Additional Observations: None

Dose #:

Doses n Series: 5

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D409QS2433

Exp Date: 9/4/2014

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified

Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)

DAPTACEL (NDC 49281-0286-01)"

Date Administered: 5/22/2014

Additional Observations:

Dose #: 3

Doses in Series: 5

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D409QS3255

Exp Date: 12/1/2014

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified

Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)

DAPTACEL (NDC 49281-0286-01)"

Date Administered: 2/21/2015

Additional Observations:

Dose #: 4

Doses in Series: 5

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D409QS249

Exp Date: 3/1/2015

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Deltoid (HL7 LD)

Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified

Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)

DAPTACEL (NDC 49281-0286-01)"

Date Administered: 11/20/2017

Additional Observations:

Dose #: 5

Doses in Series: 5

Valid Dose: Y

Ordering Provider: J. Rodriguez

Entered By: Sandra Molina

Entering Organization: Shoreline Pediatrics

Administered Amt: .05 mL

Administering Provider: Linda Casera

Administered at Location: 4253 Standish Way, Stamford Connecticut 06903

Lot#: D643QS8243

Exp Date: 12/01/2017

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Deltoid (HL7 LD)

Vaccine Group: Hib, unspecified formulation

Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)

PedvaxHIB (NDC 00006-4897-00)"

Date Administered: 1/22/2013

Additional Observations:

Dose #: 1

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 7M54K9245

Exp Date: 3/24/2014

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: Hib, unspecified formulation

Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)

PedvaxHIB (NDC 00006-4897-00)"

Date Administered: 3/23/2014

Additional Observations:

Dose #: 2

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 7M55K3342

Exp Date: 10/30/2014

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: Hib, unspecified formulation

Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)

PedvaxHIB (NDC 00006-4897-00)"

Date Administered: 5/22/2014

Additional Observations:

Dose #: 3

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 7M75K4566

Exp Date: 5/23/2014

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: Hib, unspecified formulation

Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)

PedvaxHIB (NDC 00006-4897-00)"

Date Administered: 11/21/2014

Additional Observations:

Dose #: 4

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 7M53K5534

Exp Date: 2/22/2015

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Deltoid (HL7 LD)

Vaccine Group: poliovirus vaccine, inactivated

Administered: poliovirus vaccine, inactivated (CVX 10)

IPOL (NDC 49281-0860-55)

Date Administered: 1/22/2014

Additional Observations:

Dose #: 1

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D333PV2431

Exp Date: 10/4/2014

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Subcutaneous (NCIT C38299, HL70162: SC)

Site: Left Deltoid (HL7 LD)

Vaccine Group: poliovirus vaccine, inactivated

Administered: poliovirus vaccine, inactivated (CVX 10)

IPOL (NDC 49281-0860-55)

Date Administered: 3/23/2014

Additional Observations:

Dose #: 2

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D333PV4344

Exp Date: 3/23/2014

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Subcutaneous (NCIT C38299, HL70162: SC)

Site: Left Deltoid (HL7 LD)

Vaccine Group: poliovirus vaccine, inactivated

Administered: poliovirus vaccine, inactivated (CVX 10)

IPOL (NDC 49281-0860-55)

Date Administered: 2/21/2015

Additional Observations:

Dose #: 3

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D335PV9644

Exp Date: 4/22/2016

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Subcutaneous (NCIT C38299, HL70162: SC)

Site: Left Deltoid (HL7 LD)

Vaccine Group: pneumococcal, unspecified formulation

Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)

PREVNAR 13 (NDC 00005-1971-05)"

Date Administered: 1/22/2013

Additional Observations:

Dose #: 1

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: P243V3281

Exp Date: 1/30/2013

Manufacturer: Pfizer, Inc (MVX PFR)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: pneumococcal, unspecified formulation

Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)

PREVNAR 13 (NDC 00005-1971-05)"

Date Administered: 3/23/2014

Additional Observations:

Dose #: 2

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: P343V8321

Exp Date: 3/30/2014

Manufacturer: Pfizer, Inc (MVX PFR)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: pneumococcal, unspecified formulation

Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)

PREVNAR 13 (NDC 00005-1971-05)"

Date Administered: 5/22/2014

Additional Observations:

Dose #: 3

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: P853V2164

Exp Date: 8/30/2014

Manufacturer: Pfizer, Inc (MVX PFR)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: pneumococcal, unspecified formulation

Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)

PREVNAR 13 (NDC 00005-1971-05)"

Date Administered: 1/11/2015

Additional Observations:

Dose #: 4

Doses in Series: 4

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: P853V58532

Exp Date: 4/18/2015

Manufacturer: Pfizer, Inc (MVX PFR)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Deltoid (HL7 LD)

Vaccine Group: rotavirus, unspecified formulation

Administered: rotavirus, live, monovalent vaccine (CVX 119)

ROTARIX (NDC 58160-0854-52)"

Date Administered: 1/22/2014

Additional Observations:

Dose #: 1

Doses in Series: 3

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: 1 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 6359RV533

Exp Date: 2/15/2014

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: rotavirus, unspecified formulation

Administered: rotavirus, live, monovalent vaccine (CVX 119)

ROTARIX (NDC 58160-0854-52)"

Date Administered: 3/23/2014

Additional Observations:

Dose #: 2

Doses in Series: 3

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: 1 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 6359RV932

Exp Date: 5/10/2014

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: influenza, unspecified formulation

Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)

FLUZONE QUADRIVALENT (NDC 49281-0514-25)"

Date Administered: 9/25/2014

Additional Observations:

Dose #: 1

Doses in Series: 2

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .25 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D8043IN8734

Exp Date: 3/12/2014

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Thigh (HL7 LT)

Vaccine Group: influenza, unspecified formulation

Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)

FLUZONE QUADRIVALENT (NDC 49281-0514-25)"

Date Administered: 10/29/2014

Additional Observations:

Dose #: 2

Doses in Series: 2

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .25 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D8043IN8734

Exp Date: 3/12/2015

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Thigh (HL7 RT)

Vaccine Group: influenza, unspecified formulation

Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)

FLUZONE QUADRIVALENT (NDC 49281-0514-25)"

Date Administered: 10/2/2015

Additional Observations:

Dose #:

Doses in Series:

Valid Dose:

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .25 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D9334IN9333

Exp Date: 5/22/2016

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Deltoid (HL7 LD)

Vaccine Group: influenza, unspecified formulation

Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)

FLUZONE QUADRIVALENT (NDC 49281-0514-25)"

Date Administered: 11/4/2016

Additional Observations:

Dose #:

Doses in Series:

Valid Dose:

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .25 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: D9553IN2243

Exp Date: 4/30/2017

Manufacturer: Sanofi Pasteur Inc (MVX PMC)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Deltoid (HL7 LD)

Vaccine Group: influenza, unspecified formulation

Administered: Influenza, seasonal, injectable, preservative Free (CVX 140)

Fluvirin (NDC 66521-0118-02

)

Date Administered: 10/15/2017

Additional Observations:

Dose #:

Doses in Series:

Valid Dose:

Ordering Provider: Frank Smith

Entered By: Sandra Molina

Entering Organization: Shoreline Pediatrics

Administered Amt: .5 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 8L4B3423|

Exp Date: 12/30/2017

Manufacturer: Novartis (MVX NOV)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Deltoid (HL7 LD)

Vaccine Group: influenza, unspecified formulation

Administered: Influenza, seasonal, injectable, preservative Free (CVX 140)

Fluvirin (66521-0118-02)

Date Administered: Current Date

Additional Observations:

Dose #:

Doses in Series:

Valid Dose:

Ordering Provider: Frank Smith

Entered By: Sandra Molina

Entering Organization: Shoreline Pediatrics

Administered Amt: .5 mL

Administering Provider: Sandra Molina

Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901

Lot#: 8L4B3521

Exp Date: 12/31/2019

Manufacturer: Novartis (MVX NOV)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site:Left Deltoid (HL7 LD)

Vaccine Group: Hep A, unspecified formulation

Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)

HAVRIX (NDC 58160-0825-52)"

Date Administered: 11/23/2014

Additional Observations:

Dose #: 1

Doses in Series: 2

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 6359RT33

Exp Date: 1/4/2015

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Right Deltoid (HL7 RD)

Vaccine Group: Hep A, unspecified formulation

Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)

HAVRIX (NDC 58160-0825-52)"

Date Administered: 5/23/2015

Additional Observations:

Dose #: 2

Doses in Series: 2

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 6359RT48

Exp Date: 9/11/2015

Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)

Route: Intramuscular (NCIT C28161, HL70162: IM)

Site: Left Deltoid (HL7 LD)

Vaccine Group: MMR

Administered: measles, mumps, rubella virus vaccine (CVX 03)

MMR II (NDC 0006-4681-00)"

Date Administered: 08/22/2014

Additional Observations:

Dose #:

Doses in Series: 2

Valid Dose: N

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 0853CC

Exp Date: 12/15/2014

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Subcutaneous (NCIT C38299, HL70162: SC)

Site: Left Thigh (HL7 LT)

Vaccine Group: MMR

Administered: measles, mumps, rubella virus vaccine (CVX 03)

MMR II (0006-4681-00)"

Date Administered: 11/22/2017

Additional Observations: Invalid because it was given too soon

Dose #: 1

Doses in Series: 2

Valid Dose: Y

Ordering Provider: Carlos Herrera

Entered By: J. Martinez

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 0854FF

Exp Date: 4/13/2018

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Subcutaneous (NCIT C38299, HL70162: SC)

Site: Left Deltoid (HL7 LD)

Vaccine Group: MMR

Administered: measles, mumps, rubella virus vaccine (CVX 03)

MMR II (NDC 0006-4681-00)"

Date Administered: 14 days PRIOR to day of TEST

Additional Observations: Reaction (LOINC 31044-1)/fever of >40.5C (105F) within 48 hours of dose (CDCPHINVS XC12)

Dose #: 2

Doses in Series: 2

Valid Dose: Y

Ordering Provider: Sandra Molina

Entered By: Frank Smith

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: Sandra Molina

Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901

Lot#: 0934GG

Exp Date: 12/31/2019

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Subcutaneous (NCIT C38299, HL70162: SC)

Site: Left Deltoid (HL7 LD)

Vaccine Group: Varicella

Administered: Varicella vaccine (CVX 21)

VarivaxI (NDC 0006-4827-00)"

Date Administered: 12/15/2015

Dose #: 1

Doses in Series: 2

Valid Dose: Y

Ordering Provider: J. Martinez

Entered By: Carlos Herrera

Entering Organization: Oceanview Pediatrics

Administered Amt: .05 mL

Administering Provider: J. Martinez

Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901

Lot#: 2341BB

Exp Date: 12/1/2016

Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)

Route: Subcutaneous (NCIT C38299, HL70162: SC)

Site: Left Deltoid (HL7 LD)

Vaccine Group: IPV

Due Date: 10/31/2017

Earliest Date to Give: 10/31/2017

Overdue Date: 10/31/2019

Immunization Schedule: ACIP

Vaccine Group: varicella

Due Date: 10/31/2017

Earliest Date to Give: 10/31/2017

Overdue Date: 10/31/2019

Immunization Schedule: ACIP

Notes

The immunization report may provide a subset of demographic information sufficient to identify the patient. Any demographic information included should be evaluated against the listed demographic information for accuracy.

The immunization report does not need to display all of the information listed in the evaluation criteria for each vaccination, but they do need to produce the complete list of vaccines given and the date.

The tester is requested to document separately the success or failure of the Immunization History and the Immunization forecast as these two requirements are tested concurrently.

Influenza vaccine should be due between September and October of the flue season, which may show as the prior year to testing or the year of testing.

2.5. Juana Mariana Vazquez Provide Patient Access to Immunization Report

Provide patient access to the immunization record for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.). Immunizations provided during the test are presented for patient access (e.g., through a portal).

Test Story

Description
Following the vaccination visit, the provider uses the EMR to produce an immunization report that can be accessed by the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) and the vaccine forecast.

Comments
No Comments

Pre-condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered.

Post-Condition
The patient/parent has been provided access to ta patient immunization history record.

Test Objectives

Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers.

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
No Note

2.5.1. Produce an immunization report for Juana Mariana Vazquez including all history

Test Step Type: SUT_MANUAL
The EMR, patient portal, or other user interface is used to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.).

Test Story

Description
Following the vaccination visit, the patient/parent uses the specified interface to access the immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Comments
No Comments

Pre-condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. The parent/patient is provided with an account to access the immunization history.

Post-Condition
The patient/parent has been provided a patient immunization history report.

Test Objectives
Provide Access to Patient Immunization Record: The EHR or other clinical software system provides patients and their authorized representatives with electronic access to immunization records (either directly or by interacting with an external system such as a patient portal).

Evaluation Criteria

Using the patient facing features (e.g. portal), show that the vaccine history can be displayed including today's vaccine/forecast:

Additional Observations:
Dose #: 5
Doses in Series: 5
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: Sandra Molina
Entering Organization: Shoreline Pediatrics
Administered Amt: .05 mL
Administering Provider: Linda Casera
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D643QS8243
Exp Date: 12/01/2017
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)

Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 1/22/2014
Additional Observations:
Dose #: 1
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7M54K9245
Exp Date: 3/24/2014
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)

Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 3/23/2014
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7M55K3342
Exp Date: 10/30/2014
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)

Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 5/22/2014
Additional Observations:
Dose #: 3
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7M75K4566
Exp Date: 5/23/2014
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)

Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 11/21/2014
Additional Observations:
Dose #: 4
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7M53K5534
Exp Date: 2/22/2015
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)

Vaccine Group: poliovirus vaccine, inactivated
Administered: poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)
Date Administered: 1/22/2014
Additional Observations:
Dose #: 1
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D333PV2431
Exp Date: 10/4/2014
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)

Vaccine Group: poliovirus vaccine, inactivated
Administered: poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)
Date Administered: 3/23/2014
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D333PV4344
Exp Date: 3/23/2015
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)

Vaccine Group: poliovirus vaccine, inactivated
Administered: poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)
Date Administered: 2/21/2015
Additional Observations:

Adverse Reaction of (VXC12^fever of >40.5C (105F) within 48 hours of dose^CDCPHINVS)

Notes

If the same immunization report verified in TestCase 4 for Juana Mariana Vazquez is used for the patient access to the immunization record, then content verification does not need to be repeated.

Influenza vaccine should be due between September and October of the flu season, which may show as the prior year to testing or the year of testing.

3. Juan Marcel Marina Visit

Juan Marcel Marina visits the provider where his immunization history is retrieved from the registry and reconciled with the local information in the medical record to determine vaccines that are due. Vaccinations are ordered and administered. The vaccines are reported to the immunization registry and a vaccine summary is available for the patient.

Test Story

Description

Comments

Pre-condition

Post-Condition

Test Objectives

Evaluation Criteria

Notes

3.1. Query the Registry for Juan Marcel Marina

EMR Generates a Z44 query to the Immunization Registry to retrieve the Evaluated History and Forecast for Juan Marcel Marina.

Test Story

Description

The EMR Generates a Z44 query to the Immunization Registry to retrieve the Evaluated History and Forecast for Juan Marcel Marina. Querying the registry will consist of the vendor creating Z44 messages for Juan Marcel Marina to be sent to the registry. The response will be processed as part of the 'Display, Reconcile, Import and Update Immunization Information' activity.

Comments
No Comments

Pre-condition
Juan Marcel Marina is entered as a patient in the EMR with complete Demographic data, Immunization History Data, and Clinical Data according to the steps in the 'Juan Marcel Marina Initial Data Load'

Post-Condition
A Z44 Query is generated and submitted to the Immunization Registry/Test tool, and a Z42 response is returned .

Test Objectives

Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (QBP/RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5).

Support for:

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
No Note

3.1.1. Select Patient Juan Marcel Marina

Test Step Type: SUT_MANUAL
Select patient Juan Marcel Marina, distinguishing the patient from other patients with similar demographics (similar names).

Test Story

Description
Juan Marcel Marina is selected as the patient and his record is opened in the EMR.

Comments
No Comments

Pre-condition
Juan Marcel Marina Initial Data Load completed.

Post-Condition
Juan Marcel Marina is the active working patient in the EMR.

Test Objectives

Evaluation Criteria

Tester shall verify that the product can distinguish Juan Marcel Gonzales from similar sounding names using all of the pediatric demographics:

Patient ID (previously listed as "Medicaid Number") - Vendor supplied
Patient ID: Assigning Authority ID (i.e., owning source)/Facility Name - Shoreline Pediatrics
Patient ID: Type (e.g., medical record number, IIS ID) - Vendor supplied
Patient Name: First - Juan
Patient Name: Middle - Marcel
Patient Name: Last - Marina
Patient Date of Birth - 03/04/2017
Birth Time - 11:00
Patient Gender (Administrative Sex) - M
Patient Multiple Birth Indicator - No
Patient Birth Order - NA
Responsible Person Name: First - Manuel
Responsible Person Name: Middle - Marcel
Responsible Person Name: Last - Marina
Responsible Person Name: Relationship to Patient - Father
Mother's Name: First - Anita
Mother's Name: Middle - Francesca
Mother's Name: Last - Marina
Mother's Name: Maiden Last - Morales
Patient Address: Street - 4623 Standish Way
Patient Address: City - Stamford
Patient Address: State - CT
Patient Address: Country - US
Patient Address: Zipcode - 06903
Patient Address: County of Residence - Fairfield
Race - White
Ethnicity - Hispanic or Latino
Birthing Facility Name (Birth Delivery Location Address BDL) - Shoreline Hospital 325 Shoreline Drive, Stamford Connecticut 06901
Patient Birth State - CT
Patient Primary Language - English
Patient Telephone Number - (203) 555-1213
Patient Telephone Number Type (e.g., home, cell) - home
Patient E-mail Address -
Publicity Code- Reminder/recall - no calls (03 HL70215)
Protection Indicator
Protection Indicator Effective Date
Immunization Registry Status
Preferred Contact Method - Text

Notes
No Note

3.1.2. Query Registry for vaccination history and forecast for Juan Marcel Marina

Test Step Type: SUT_INITIATOR
The EMR generates a Z44 query for immunization history and forecast correctly and without omission according to supplied test data.

Test Story

Description
The provider uses the EMR to query the Immunization Registry for an Evaluated History and Forecast based on information known to the Immunization Registry.

Comments
No Comments

Pre-condition

Juan Marcel Marina Initial Data Load is completed.

Juan Marcel Marina is the active working patient in the EMR.

Post-Condition
The Immunization Registry responds with Evaluated Vaccine History and Forecast for Juan Marcel Marina.

Test Objectives

Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (QBP/RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5).

Evaluation Criteria

Tester shall verify that the vendor can produce a valid Z44 query in accordance with the test data correctly and without omission.

Tester shall verify that the data in the message corresponds to the data in the EMR and contains all test data attributes supplied.

Notes
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20180515001020-0500
MSH-9	Message Type
MSH-9.1	Message Code	QBP
MSH-9.2	Trigger Event	Q11
MSH-9.3	Message Structure	QBP_Q11
MSH-10	Message Control ID	793543
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z44
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

QPD : Query Parameter Definition

Location	Data Element	Data	Categorization
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number	123456
QPD-3.4	Assigning Authority
QPD-3.5	Identifier Type Code	MR
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Marina	Value-Test Case Fixed
QPD-4.2	Given Name	Juan	Value-Test Case Fixed
QPD-4.3	Second and Further Given Names or Initials Thereof	Marcel	Value-Test Case Fixed
QPD-4.7	Name Type Code	L	Value-Test Case Fixed
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Morales	Value-Test Case Fixed
QPD-5.7	Name Type Code	M	Value-Test Case Fixed
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201703041100	Value-Test Case Fixed
QPD-7	Patient Sex	M	Value-Test Case Fixed
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	4623 Standish Way	Value-Test Case Fixed
QPD-8.2	Other Designation
QPD-8.3	City	Stamford	Value-Test Case Fixed
QPD-8.4	State or Province	CT	Value-Test Case Fixed
QPD-8.5	Zip or Postal Code	06903	Value-Test Case Fixed
QPD-8.6	Country
QPD-8.7	Address Type	L	Value-Test Case Fixed
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN	Value-Test Case Fixed
QPD-9.3	Telecommunication Equipment Type	CP	Value-Test Case Fixed
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203	Value-Test Case Fixed
QPD-9.7	Local Number	5551213	Value-Test Case Fixed
QPD-10	Multiple birth indicator	N
QPD-11	Birth order

RCP : Response Control Parameter

Location	Data Element	Data
RCP-1	Query Priority	I
RCP-2	Quantity Limited Request
RCP-2.1	Quantity	1
RCP-2.2	Units
RCP-2.2.1	Identifier	RD
RCP-2.2.2	Text	Records
RCP-2.2.3	Name of Coding System	HL70126

Test Data Specification

Patient Information

Element	Data
Patient Name	Juan Marcel Marina
Mother's Maiden Name	Morales
ID Number	123456
Date/Time of Birth	03/04/2017 11:00
Sex	Male
Patient Address	4623 Standish Way Stamford CT 06903
Patient Phone	(203)555-1213
Birth Indicator	No
Birth Order

3.1.3. View and import response to request for vaccination history for Juan Marcel Marina

Test Step Type: TA_RESPONDER
The EMR displays the Immunization History results (Z42) returned in response to the Z44 Query and import them into the EMR

Test Story

Description

The physician accesses the record for Juan Marcel Marina and:

- Accepts the vaccines provided by the registry as this is a new patient and there are no prior vaccines recorded

Comments
There is no reconciliation step as there are no historical immunizations in the EMR. All will be imported from the Z42 response.

Pre-condition

A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import.

Post-Condition
Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juan Marcel Marina)

Test Objectives

Compare Public Health Immunization Registry (IIS) Immunization History to EHR Immunization History: The public health immunization registry has returned the requested immunization history for a patient. The EHR is able to display the immunization history received from the registry as well as the immunization history already present in the EHR so that a user can compare them. The EHR provides a way for the provider to view both histories, determine what is different (if anything), and update the existing EHR immunization history with new information from the public health registry if he or she chooses to do so. The system must store the new information as structured data as part of the patient's local immunization history and include the time of the update and the source of the new information.

Review Patient Immunization History: To assist with the ordering process, the EHR or other clinical software system allows a user to specify standard views of patient immunization information for each vaccine dose administration, including patient-specific data (e.g., age on dates of administration, etc.).

Supporting data for:

Evaluation Criteria

1. The EMR displays the information returned from the Immunization Registry according to the Juror Document.2. The user imports returned vaccinations as follows using only the vaccination, and administration dates returned from the Immunization Registry:

a. Vaccinations Imported:

hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 3/4/2017

hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 4/15/2017

diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 5/15/2017

diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 7/13/2017

diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 9/16/2017

diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 9/20/2018

Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 5/14/2017

Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 7/21/2017

Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 9/27/2017

Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 5/4/2018

poliovirus vaccine, inactivated (CVX 10) administered 5/14/2017

poliovirus vaccine, inactivated (CVX 10) administered 7/21/2017

poliovirus vaccine, inactivated (CVX 10) administered 10/15/2017

pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 5/18/2017

pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 7/21/2017

pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 9/27/2017

pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 5/4/2018

rotavirus, live, monovalent vaccine (CVX 119) administered 5/18/2017

rotavirus, live, monovalent vaccine (CVX 119) administered 7/21/2017

Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 9/27/2017

Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/20/2018

measles, mumps, rubella virus vaccine (CVX 03) administered 6/20/2018

Notes
The EMR must minimally display the vaccine administered and the date of the immunization.

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20181130020020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	793543

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	37374859
QAK-2	Query Response Status	OK
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Marina
QPD-4.2	Given Name	Juan
QPD-4.3	Second and Further Given Names or Initials Thereof	Marcel
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Morales
QPD-5.7	Name Type Code	L
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201703041100
QPD-7	Patient Sex	M
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code	06903
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	CP
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551213
QPD-10	Multiple birth indicator
QPD-11	Birth order

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Marina
PID-5.2	Given Name	Juan
PID-5.3	Second and Further Given Names or Initials Thereof	Marcel
PID-5.7	Name Type Code	L
PID-7	Date/Time of Birth
PID-7.1	Time	201703041100
PID-8	Administrative Sex	M
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	4623 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Shoreline Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	OP
ORC-17.2	Text	Oceanview Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170304
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170415
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170515
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170713
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170916
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20180820
RXA-5	Administered Code
RXA-5.1	Identifier	106
RXA-5.2	Text	DTaP
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170514
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170721
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170927
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20180504
RXA-5	Administered Code
RXA-5.1	Identifier	49
RXA-5.2	Text	Hib
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170514
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170721
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20171015
RXA-5	Administered Code
RXA-5.1	Identifier	10
RXA-5.2	Text	Polio (IPV)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170518
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170721
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170927
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20180504
RXA-5	Administered Code
RXA-5.1	Identifier	133
RXA-5.2	Text	Pneumococcal conjugate (PCV13)
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170518
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	Rotavirus
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	1.0
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170921
RXA-5	Administered Code
RXA-5.1	Identifier	119
RXA-5.2	Text	Rotavirus
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	1.0
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170927
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20171020
RXA-5	Administered Code
RXA-5.1	Identifier	161
RXA-5.2	Text	Influenza
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.25
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20180620
RXA-5	Administered Code
RXA-5.1	Identifier	03
RXA-5.2	Text	measles, mumps, rubella virus vaccine
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38288
RXR-1.2	Text	Oral
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38288
RXR-1.2	Text	Oral
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Thigh Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	hepatitis B vaccine, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20170304

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	hepatitis B vaccine, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20170415

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20170515

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20170713

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20170916

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20180820

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	5
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20170514

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20170721

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20170927

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20180504

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20170514

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	poliovirus vaccine, inactivated
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20170721

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20171015

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20170518

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20170721

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20170927

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	109
OBX-5.2	Text	pneumococcal, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20180504

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	4
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20170518

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20170921

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20170927

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20171020

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20170620

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	Hep B, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20170831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20170831
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180304
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180304
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, pediatric, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180304
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20180304
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

Juror Document

Evaluated Immunization History and Immunization Forecast

Test Case ID

Query the Registry for Juan Marcel Marina

Inspection Settlement (Pass/Fail)

Pass	Fail

Reason Failed

Juror Comments

DISPLAY VERIFICATION

The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.

Patient Information
Element Name	Data	Tester Comment
Patient Identifier
ID Number	123456
Assigning Authority
Namespace ID	MYEHR
ID Type	MR
Patient Identifier
ID Number	987633
Assigning Authority
Namespace ID	MYIIS
ID Type	SR
Name	Juan Marcel Marina
Date of Birth	03/04/2017
Sex	Male
Address 1
Street	4623 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country	USA
Address Type	L
Mother's Maiden Name	Anita Francesca Morales
When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient.

Evaluated Immunization History Information
Element Name	Data	Tester Comment
Entering Organization	Shoreline Hospital
Vaccine Group	hepatitis B vaccine, unspecified formulation
Vaccine Administered	Hepatitis B
Refusal Reason
Date/Time Administration-Start	03/04/2017
Date/Time Administration-End	03/04/2017
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	325 Shorline Drive
Other Designation
City	Stamford
State	CT
Zip Code	06901
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	hepatitis B vaccine, unspecified formulation
Vaccine Administered	Hepatitis B
Refusal Reason
Date/Time Administration-Start	04/15/2017
Date/Time Administration-End	04/15/2017
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Right Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	DTaP
Refusal Reason
Date/Time Administration-Start	05/15/2017
Date/Time Administration-End	05/15/2017
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	DTaP
Refusal Reason
Date/Time Administration-Start	07/13/2017
Date/Time Administration-End	07/13/2017
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	DTaP
Refusal Reason
Date/Time Administration-Start	09/16/2017
Date/Time Administration-End	09/16/2017
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Vaccine Administered	DTaP
Refusal Reason
Date/Time Administration-Start	08/20/2018
Date/Time Administration-End	08/20/2018
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Deltoid
Substance Manufacturer Name	Sanofi Pasteur Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	5
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Hib
Refusal Reason
Date/Time Administration-Start	05/14/2017
Date/Time Administration-End	05/14/2017
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Right Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Hib
Refusal Reason
Date/Time Administration-Start	07/21/2017
Date/Time Administration-End	07/21/2017
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Hib
Refusal Reason
Date/Time Administration-Start	09/27/2017
Date/Time Administration-End	09/27/2017
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Right Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	Hib, unspecified formulation
Vaccine Administered	Hib
Refusal Reason
Date/Time Administration-Start	05/04/2018
Date/Time Administration-End	05/04/2018
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Deltoid
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	poliovirus vaccine, inactivated
Vaccine Administered	Polio (IPV)
Refusal Reason
Date/Time Administration-Start	05/14/2017
Date/Time Administration-End	05/14/2017
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Subcutaneous
Administration Site	Left Deltoid
Substance Manufacturer Name	MSanofi Pasteur Inc.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	poliovirus vaccine, inactivated
Vaccine Administered	Polio (IPV)
Refusal Reason
Date/Time Administration-Start	07/21/2017
Date/Time Administration-End	07/21/2017
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Subcutaneous
Administration Site	Left Deltoid
Substance Manufacturer Name	MSanofi Pasteur Inc.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	Polio (IPV)
Refusal Reason
Date/Time Administration-Start	10/15/2017
Date/Time Administration-End	10/15/2017
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Subcutaneous
Administration Site	Left Deltoid
Substance Manufacturer Name	MSanofi Pasteur Inc.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	Pneumococcal conjugate (PCV13)
Refusal Reason
Date/Time Administration-Start	05/18/2017
Date/Time Administration-End	05/18/2017
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	Pneumococcal conjugate (PCV13)
Refusal Reason
Date/Time Administration-Start	07/21/2017
Date/Time Administration-End	07/21/2017
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	Pneumococcal conjugate (PCV13)
Refusal Reason
Date/Time Administration-Start	09/27/2017
Date/Time Administration-End	09/27/2017
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Right Thigh
Substance Manufacturer Name	Pfizer, Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	3
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	pneumococcal, unspecified formulation
Vaccine Administered	Pneumococcal conjugate (PCV13)
Refusal Reason
Date/Time Administration-Start	05/04/2018
Date/Time Administration-End	05/04/2018
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Deltoid
Substance Manufacturer Name	Pfizer, Inc
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	4
Number of Doses in Series	4
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	rotavirus, unspecified formulation
Vaccine Administered	Rotavirus
Refusal Reason
Date/Time Administration-Start	05/18/2017
Date/Time Administration-End	05/18/2017
Administered Amount	1.0
Administered Units of Measure	mL
Route of Administration	Oral
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	rotavirus, unspecified formulation
Vaccine Administered	Rotavirus
Refusal Reason
Date/Time Administration-Start	09/21/2017
Date/Time Administration-End	09/21/2017
Administered Amount	1.0
Administered Units of Measure	mL
Route of Administration	Oral
Administration Site	Thigh Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza
Refusal Reason
Date/Time Administration-Start	09/27/2017
Date/Time Administration-End	09/27/2017
Administered Amount	0.25
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Left Thigh
Substance Manufacturer Name	Sanofi Pasteur
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	influenza, unspecified formulation
Vaccine Administered	Influenza
Refusal Reason
Date/Time Administration-Start	10/20/2017
Date/Time Administration-End	10/20/2017
Administered Amount	0.25
Administered Units of Measure	mL
Route of Administration	Intramuscular
Administration Site	Right Thigh
Substance Manufacturer Name	Sanofi Pasteur
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	2
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

Element Name	Data	Tester Comment
Entering Organization	Oceanview Pediatrics
Vaccine Group	MMR
Vaccine Administered	measles, mumps, rubella virus vaccine
Refusal Reason
Date/Time Administration-Start	06/20/2018
Date/Time Administration-End	06/20/2018
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	Subcutaneous
Administration Site	Left Thigh
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Administration Notes
Administering Provider
Name	J. Martinez
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	4253 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	2
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

* "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered".

Immunization Forecast
Element Name	Data	Tester Comment
Vaccine Group	Hep B, unspecified formulation
Vaccine Due Date	08/31/2017
Earliest Date to Give	08/31/2017
Latest Date to Give
Date When Vaccine Overdue	09/01/2018
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	influenza, unspecified formulation
Vaccine Due Date	09/01/2018
Earliest Date to Give	03/04/2018
Latest Date to Give
Date When Vaccine Overdue
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Varicella
Vaccine Due Date	03/04/2018
Earliest Date to Give	03/04/2018
Latest Date to Give
Date When Vaccine Overdue
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Hep A, pediatric, unspecified formulation
Vaccine Due Date	03/04/2018
Earliest Date to Give	03/04/2018
Latest Date to Give
Date When Vaccine Overdue
Status in Immunization Series
Forecast Reason

3.1.4. View the vaccination forecast for Juan Marcel Marina

Test Step Type: SUT_MANUAL
The EMR displays the current Immunization Forecast to the user for Juan Marcel Marina either as returned by the IIS in prior step, or as generated thru any local means.

Test Story

Description

The physician accesses the record for Juan Marcel Marina and, once the vaccine history is reconciled in the EMR, the vaccine forecast is updated.

- The provider views the updated vaccine forecast (either as provided by the Immunization Registry or as determined through EMR defined methods)

Comments
The vaccine forecast may be imported from the Immunization Registry Vaccination History and Forecast (Z42) response, or it may be generated by EMR defined means.

Pre-condition
EMR Vaccine History is imported from the Immunization History returned from the Immunization Registry (previous step 'View and import response to request for vaccination history for Juan Marcel Gonzales)

Post-Condition
A vaccine forecast based upon the imported vaccine history is available to the user.

Test Objectives

View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient's newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service.

Modify Antigen Recommendations Based on Active Diagnoses: The system notifies the provider of any conflicts between recommended vaccines in the updated forecast and the patient's current or historical diagnoses.

Evaluation Criteria

1. Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history:
2. Verify that the EMR includes in the vaccine forecast:

Hep B Peds NOS due on 8/31/2017
influenza, unspecified formulation due on Sep 1, 2018 or later (annual recommendation - specific date may vary somewhat)

In support of test objective 'Modify Antigen Recommendations Based on Active Diagnoses' the tester verifies that the system notifies the provider that:

1. Varicella due on 3/4/2018 - Forecast should not show that they need vaccine for Varicella; because of known diagnosis that this is due.

2. Hep A is due 3/4/2018 - Forecast may not show that they need the vaccine for Hepatitis A due to serologic immunity to the disease.

Notes

The due date must be in range for the date shown. Vaccine forecast dates may be plus or minus 10 days to accommodate differences in date handling.

Further variation should be documented in the notable exceptions, but minimally each forecast vaccine must be present.

Tester should document how evidence of prior disease (Varicella) is documented (e.g. if not in forecast, is there a reason available to clinician).
Manual override does not fulfill the 'modify antigen recommendations based on active diagnosis' (e.g. if the system does not support this through CDS then not fulfilled)
This criteria is considered 'Advanced', so tester should note support for this criteria separately.

3.2. Juan Marcel Marina, Enter Orders and Immunizations

Orders and Immunization events, non-administrations, and alerts presented for current visit.

Test Story

Description
This test will consist of ordering vaccines for the test patients, reviewing any alerts caused by specific scenarios, and documenting vaccinations administered to the patients.

Comments
No Comments

Pre-condition
Juan Marcel Marina is entered as a patient in the EMR with complete Demographic data, Immunization History Data, and Clinical Data according to the steps in the 'Juan Marcel Marina Initial Data Load'

Post-Condition
Visit orders are entered in Juan Marcel Marina's record.

Test Objectives

Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines.

Notify of Vaccine Dose Expiration: The EHR or other clinical software system notifies the provider administering a vaccine if the dose chosen for administration is expired.

Notify of Vaccine Dose Ineligibility: The EHR or other clinical software system provides a method for alerting a provider if a vaccine is selected for a patient who is not eligible for the inventory item selected.

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
No Note

3.2.1. Orders administration of Hepatitis B vaccine

Test Step Type: SUT_MANUAL
The provider orders a Hepatitis B vaccine (dose 3).

Test Story

Description
As indicated by the vaccine forecast, the third Hepatitis B is overdue, and is ordered.

Comments
No Comments

Pre-condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. Vaccine forecast reviewed.

Post-Condition
Hepatitis B vaccine is ordered for the patient.

Test Objectives
Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines.

Evaluation Criteria

EMR Records the following order information:. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source	New immunization record (NIP001 00)
Order Value/Text for Vaccine Type	hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08, NDC 58160-0820-11)
Date/Time Vaccine was recorded	Current Date

Notes
No Note

3.2.2. Orders administration of DTaP vaccine and alerted that the dose is too early

Test Step Type: SUT_MANUAL
The provider orders a DTaP vaccine (dose 5). The EMR provides an alert that the vaccine dose is too early.

Test Story

Description
The fifth DTaP is ordered, and the provider is notified that the dose is too early.

Comments
No Comments

Pre-condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. Vaccine forecast is available in the EMR.

Post-Condition
DTaP vaccine is ordered for the patient, and provider is notified that the dose is too early.

Test Objectives

Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines.

Evaluation Criteria

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source	New immunization record (NIP001 00)
Value/Text for Vaccine Type	diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
Date/Time Vaccine order was recorded	Current Date
Alert	Notification that the dose is too early

Notes
No Note

3.2.3. Attempt to record HepB Vaccine administration route with data validation checking

Test Step Type: SUT_MANUAL
The provider records the vaccine administration route in the EMR and is prevented from incorrectly documenting vaccine route

Test Story

Description
The nurse documents administration route for the HepB vaccine - Is prevented from documenting "oral" for HepB vaccine

Comments
This step covers data quality checking as an informative aspect of vaccine administration

Pre-condition
Order is placed for HepB vaccine.

Post-Condition
The HepB vaccination route has failed to be recorded as 'oral' in the EMR.

Test Objectives

Evaluation Criteria
The EMR prevents the user for entering 'Oral' as a route for the the HepB vaccine.

Notes
No Note

3.2.4. Records Hepatitis B Vaccine lot number with expired lot alert

Test Step Type: SUT_MANUAL
The provider records the vaccine administration lot number in the EMR and is alerted of the expired lot.

Test Story

Description
The nurse documents administration lot number for the Hepatitis B vaccine - Is prevented from ordering the Hepatitis B lot as it has expired - Documents administration from a different lot that is not expired

Comments
No Comments

Pre-condition
Order is placed for Hepatitis B vaccine.

Post-Condition
The provider has been notified of the expired Hepatitis B vaccination lot. Documentation of a lot to be administered that is not expired is recorded in the EMR.

Test Objectives
Notify of Vaccine Dose Expiration: The EHR or other clinical software system notifies the provider administering a vaccine if the dose chosen for administration is expired.

Evaluation Criteria

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source	New immunization record (NIP001 00)
Date/Time of Start of Administration	Current Date
Vaccine Administered	hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-43)
Lot Number (Expired)	6332FK18
Substance Expiration Date (Expired)	6/15/2018
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA (MVX SKB)
Alert	Alerts user to expired lot

Notes
No Note

3.2.5. Record Hepatitis B Vaccine administration

Test Step Type: SUT_MANUAL
The EMR is able to document all attributes associated with the new vaccine administration.

Test Story

Description

The nurse administers the the Hepatitis B vaccine
• Documents all required information for the vaccine

Comments
No Comments

Pre-condition
Order is placed for Hepatitis B vaccine.

Post-Condition
The Hepatitis B vaccination is recorded in the EMR.

Test Objectives

Evaluation Criteria

EMR Records the following vaccine administration information. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source	New immunization record (NIP001 00)
Date/Time of Start of Administration	Current Date
Vaccine Administered	hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-43)
Administered Amount (of Vaccine)	0.5
Administered Units (of Measure)	mL
Administration Notes
Administering Provider	Sandra Molina
Administered-at Location	400 Shoreline Drive, Stamford Connecticut 06901
Lot Number	6332FK26
Substance Expiration Date	10/31/2019
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA (MVX SKB)
Completion Status	Completed (CP)
Route of Administration	Intramuscular (NCIT C28161, HL70162: IM)
Administration Site	Left Deltoid (HL70163 LD)
VFC Eligibility	No
Funding Source	Private

Notes
The EMR does not need to specify a 'new immunization', as long as there is a way to indicate that it is a new immunization within the EMR, this is acceptable (e.g. the default interpretation of the data entry is that it is a new immunization and not historical).

3.2.6. Records Influenza Vaccine administration with VFC eligibility checking

Test Step Type: SUT_MANUAL
The provider records the vaccine administration from a VFC source and alerted that the patient is not VFC eligible.

Test Story

Description
The nurse documents administration for the inactivated influenza vaccine from a VFC source - Is alerted that the patient is not eligible for VFC - Orders a different non-VFC lot of inactivated influenza vaccine

Comments
No Comments

Pre-condition
Order is placed for inactivated influenza vaccine.

Post-Condition
The user is notified of vaccine dose ineligibility.

Test Objectives
Notify of Vaccine Dose Ineligibility: The EHR or other clinical software system provides a method for alerting a provider if a vaccine is selected for a patient who is not eligible for the inventory item selected.

Evaluation Criteria

The provider documents a VFC lot to be administered in the EMR. Once notified that the patient is not eligible for the VFC, then a non-VFC lot is selected. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source	New immunization record (NIP001 00)
Value/Text for Vaccine Type	Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161), FLUZONE QUADRIVALENT (NDC 49281-0413-58)
Date/Time of Start of Administration	Current Date
Vaccine Administered	Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161), FLUZONE QUADRIVALENT (NDC 49281-0413-58)
VFC lot (not administered)	D8043IN8422
Substance Expiration Date	12/31/2019
Substance Manufacturer Name	Sanofi Pasteur (MVX PMC)
Alert	Patient is not VFC Eligible
Funding Source	Private

The Provider selects a non-VFC Lot:

Vaccine Lot # (administered):	D8043IN8855
Vaccine Expiration Date:	12/31/2019

Notes
No Note

3.2.7. Record Influenza Vaccine administration for Juan Marcel Marina

Test Step Type: SUT_MANUAL
The EMR is able to document all attributes associated with the new vaccine administration.

Test Story

Description

The nurse administers the inactivated influenza vaccine
- Documents all required information for each vaccine

Comments
No Comments

Pre-condition
Order is placed for inactivated influenza vaccine.

Post-Condition
The inactivated influenza vaccine administration is recorded in the EMR.

Test Objectives

Evaluation Criteria

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source (Administration Notes)	New immunization record (NIP001 00)
Value/Text for Vaccine Type	Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161), FLUZONE QUADRIVALENT (NDC 49281-0413-58)
Date/Time of Start of Administration	Current Date
Vaccine Administered	Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161), FLUZONE QUADRIVALENT (NDC 49281-0413-58)
Administered Amount (of Vaccine)	0.5
Administered Units (of Measure)	mL
Administering Provider	Sandra Molina
Administered-at Location	400 Shoreline Drive, Stamford Connecticut 06901
Lot Number	D8043IN8855
Substance Expiration Date	12/31/2019
Substance Manufacturer Name	Sanofi Pasteur (MVX PMC)
Completion Status	CP
Route of Administration	Intramuscular (NCIT C28161, HL70162: IM)
Administration Site	Left Thigh (HL7 LT)
VFC Eligibility	No
Funding Source	Private

Notes
The EMR does not need to specify a 'new immunization', as long as there is a way to indicate that it is a new immunization within the EMR, this is acceptable (e.g. the default interpretation of the data entry is that it is a new immunization and not historical).

3.3. Juan Marcel Marina Transmit Immunization Report

Send the Immunization Report to the Immunization Registry (VXU/Z22) for Juan Marcel Marina.

Test Story

Description
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report should include vaccines incorrectly recorded in the IIS. The report MAY send the immunizations that the EMR imported from the IIS.

Comments
No Comments

Pre-condition
The vaccines for the visit have been administered.

Post-Condition
The IIS has received the vaccine information (Z22 message).

Test Objectives

Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries.

Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization.
a. NDC codes, CVX for immunizations

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
No Note

3.3.1. Transmit the Immunization Report for Juan Marcel Marina

Test Step Type: SUT_INITIATOR
The EMR sends the Immunization Report to the Immunization Registry (VXU/Z22) for updated vaccination information from the visit. This includes all newly administered vaccines and may include historical information updated in the EMR during the visit. This also includes notification that Varicella is not administered due to history of the disease.

Test Story

Description

Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines, and an indication that Varicella was not administered due to a history of the disease as evidence of immunity. The Vaccination report also includes an indication that Hepatitis A was not administered due to serological evidence of immunity. The report MAY send the immunizations that the EMR imported from the IIS.

Comments
The Report must include all newly administered vaccines in any order. The report may include the information imported from the IIS.

Pre-condition
The vaccines for the visit have been administered. The clinical information has been documented for Juan Marcel Marina in the Initial Data Load.

Post-Condition
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission.

Test Objectives

Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries.
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content.

Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization.
a. NDC codes, CVX for immunizations

Evaluation Criteria

The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content.

This includes indication that Varicella was not administered due to history of the disease, and an indication that Hepatitis A was not administered due to serological evidence of immunity.

Notes

This message has been updated in the 2018 release to indicate that no Varicella vaccine was administered due to a history of the illness as evidence of immunity.

This message has also been updated in the 2018 release to indicate that no Hepatitis A vaccine was administered due to serological evidence of immunity.

These are not subject to the 90% rule in this introductory year.

Tester should document any issues with these new evaluation stage test features.

Message Contents

MSH : Message Header

Location	Data Element	Data	Categorization
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	Test EHR Application
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	X68
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NIST Test Iz Reg
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20180701082240-0500
MSH-9	Message Type
MSH-9.1	Message Code	VXU
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	VXU_V04
MSH-10	Message Control ID	NIST-IZ-001.00
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z22
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	IIPEHRFAC	Presence-Content Indifferent
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code	XX	Presence-Content Indifferent
MSH-22.10	Organization Identifier	100-1	Presence-Content Indifferent
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	IIPIISFAC	Presence-Content Indifferent
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code	XX	Presence-Content Indifferent
MSH-23.10	Organization Identifier	100-2	Presence-Content Indifferent

PID : Patient Identification

Location	Data Element	Data	Categorization
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Marina
PID-5.2	Given Name	Juan	Value-Test Case Fixed
PID-5.3	Second and Further Given Names or Initials Thereof	Marcel	Value-Test Case Fixed
PID-5.7	Name Type Code	L	Value-Test Case Fixed
PID-6	Mother's Maiden Name
PID-6.1	Family Name
PID-6.1.1	Surname	Morales
PID-6.7	Name Type Code	M
PID-7	Date/Time of Birth
PID-7.1	Time	201703041100	Value-Test Case Fixed
PID-8	Administrative Sex	M	Value-Test Case Fixed
PID-10	Race
PID-10.1	Identifier	2106-3	Value-Test Case Fixed
PID-10.2	Text	White	Value-Test Case Fixed
PID-10.3	Name of Coding System	CDCREC	Value-Test Case Fixed
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	4623 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford	Value-Test Case Fixed
PID-11.4	State or Province	CT	Value-Test Case Fixed
PID-11.5	Zip or Postal Code	06903	Value-Test Case Fixed
PID-11.6	Country	USA	Value-Test Case Fixed
PID-11.7	Address Type	L	Value-Test Case Fixed
PID-13	Phone Number - Home
PID-13.2	Telecommunication Use Code	PRN	Value-Test Case Fixed
PID-13.3	Telecommunication Equipment Type	CP	Value-Test Case Fixed
PID-13.4	Email Address
PID-13.6	Area/City Code	203	Value-Test Case Fixed
PID-13.7	Local Number	5551213	Value-Test Case Fixed
PID-22	Ethnic Group
PID-22.1	Identifier	2135-2	Value-Test Case Fixed
PID-22.2	Text	Hispanic or Latino	Value-Test Case Fixed
PID-22.3	Name of Coding System	CDCREC	Value-Test Case Fixed
PID-24	Multiple Birth Indicator
PID-25	Birth Order
PID-29	Patient Death Date and Time
PID-29.1	Time
PID-30	Patient Death Indicator

PD1 : Patient Additional Demographic

Location	Data Element	Data	Categorization
PD1-11	Publicity Code
PD1-11.1	Identifier	03	Value-Test Case Fixed
PD1-11.2	Text	Reminder/recall - no calls	Presence-Content Indifferent
PD1-11.3	Name of Coding System	HL70215	Value-Test Case Fixed
PD1-12	Protection Indicator	N	Value-Test Case Fixed
PD1-13	Protection Indicator Effective Date
PD1-16	Immunization Registry Status	A
PD1-17	Immunization Registry Status Effective Date	20170304	Presence-Content Indifferent
PD1-18	Publicity Code Effective Date	20170304	Presence-Content Indifferent

NK1 : Next of Kin / Associated Parties

Location	Data Element	Data	Categorization
NK1-1	Set ID - NK1	1
NK1-2	Name
NK1-2.1	Family Name
NK1-2.1.1	Surname	Gonzales
NK1-2.2	Given Name	Manuel	Value-Test Case Fixed
NK1-2.3	Second and Further Given Names or Initials Thereof	Marcel	Value-Test Case Fixed
NK1-2.7	Name Type Code	L	Value-Test Case Fixed
NK1-3	Relationship
NK1-3.1	Identifier	FTH	Value-Test Case Fixed
NK1-3.2	Text	Father	Value-Test Case Fixed
NK1-3.3	Name of Coding System	HL70063	Value-Test Case Fixed
NK1-4	Address
NK1-4.1	Street Address
NK1-4.1.1	Street or Mailing Address	4623 Standish Way
NK1-4.2	Other Designation
NK1-4.3	City	Stamford	Value-Test Case Fixed
NK1-4.4	State or Province	CT	Value-Test Case Fixed
NK1-4.5	Zip or Postal Code	06903	Value-Test Case Fixed
NK1-4.6	Country
NK1-4.7	Address Type	L	Value-Test Case Fixed
NK1-5	Phone Number
NK1-5.2	Telecommunication Use Code	PRN	Value-Test Case Fixed
NK1-5.3	Telecommunication Equipment Type	PH	Value-Test Case Fixed
NK1-5.4	Email Address
NK1-5.6	Area/City Code	203	Value-Test Case Fixed
NK1-5.7	Local Number	5551213	Value-Test Case Fixed

ORC[*]

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Sirtis	Presence-Content Indifferent
ORC-10.3	Given Name	Lisa	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Carter	Presence-Content Indifferent
ORC-12.3	Given Name	Jane	Presence-Content Indifferent
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L	Value-Test Case Fixed
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SH	Presence-Content Indifferent
ORC-17.2	Text	Shoreline Hospital	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina	Presence-Content Indifferent
ORC-10.3	Given Name	Sandra	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith	Presence-Content Indifferent
ORC-12.3	Given Name	Frank	Presence-Content Indifferent
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L	Presence-Content Indifferent
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP	Presence-Content Indifferent
ORC-17.2	Text	Shoreline Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina	Presence-Content Indifferent
ORC-10.3	Given Name	Sandra	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith	Presence-Content Indifferent
ORC-12.3	Given Name	Frank	Presence-Content Indifferent
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L	Presence-Content Indifferent
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP	Presence-Content Indifferent
ORC-17.2	Text	Shoreline Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Martinez	Presence-Content Indifferent
ORC-10.3	Given Name	J.	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Rodriguez
ORC-12.3	Given Name	J.
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	OP	Presence-Content Indifferent
ORC-17.2	Text	Oceanview Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina	Indifferent
ORC-10.3	Given Name	Sandra	Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith	Indifferent
ORC-12.3	Given Name	Frank	Indifferent
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP	Indifferent
ORC-17.2	Text	Shoreline Pediatrics	Indifferent
ORC-17.3	Name of Coding System	HL70362	Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina	Presence-Content Indifferent
ORC-10.3	Given Name	Sandra	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP	Presence-Content Indifferent
ORC-17.2	Text	Shoreline Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170304	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	08	Value-Test Case Fixed
RXA-5.2	Text	Hepatitis B	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6332FK34
RXA-16	Substance Expiration Date
RXA-16.1	Time	20171214
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170415	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	08	Value-Test Case Fixed
RXA-5.2	Text	Hepatitis B	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6352FK2
RXA-16	Substance Expiration Date
RXA-16.1	Time	20171001
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031	Presence-Content Indifferent
RXA-5	Administered Code
RXA-5.1	Identifier	08	Value-Test Case Fixed
RXA-5.2	Text	Hepatitis B	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5	Value-Test Case Fixed
RXA-7	Administered Units
RXA-7.1	Identifier	mL	Value-Test Case Fixed
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM	Value-Test Case Fixed
RXA-9	Administration Notes
RXA-9.1	Identifier	00	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina	Presence-Content Indifferent
RXA-10.3	Given Name	Sandra	Presence-Content Indifferent
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6332FK26	Value-Test Case Fixed
RXA-16	Substance Expiration Date
RXA-16.1	Time	20191231	Value-Test Case Fixed
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB	Value-Test Case Fixed
RXA-17.2	Text	GlaxoSmithKline Biologicals SA	Presence-Content Indifferent
RXA-17.3	Name of Coding System	MVX	Value-Test Case Fixed
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP	Value-Test Case Fixed
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170515	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	106	Value-Test Case Fixed
RXA-5.2	Text	DTaP	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D409QS2342
RXA-16	Substance Expiration Date
RXA-16.1	Time	20181130
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170713	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	106	Value-Test Case Fixed
RXA-5.2	Text	DTaP	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D409QS2434
RXA-16	Substance Expiration Date
RXA-16.1	Time	20170904
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170916	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	106	Value-Test Case Fixed
RXA-5.2	Text	DTaP	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D409QS250
RXA-16	Substance Expiration Date
RXA-16.1	Time	20171201
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20180820	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	106	Value-Test Case Fixed
RXA-5.2	Text	DTaP	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D409QS250
RXA-16	Substance Expiration Date
RXA-16.1	Time	20190301
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170514	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	49	Value-Test Case Fixed
RXA-5.2	Text	Hib	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	7M54K9255
RXA-16	Substance Expiration Date
RXA-16.1	Time	20180324
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170721	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	49	Value-Test Case Fixed
RXA-5.2	Text	Hib	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	7M55K3343
RXA-16	Substance Expiration Date
RXA-16.1	Time	20171030
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170927	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	49	Value-Test Case Fixed
RXA-5.2	Text	Hib	Value-Test Case Fixed
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	7M75K4577
RXA-16	Substance Expiration Date
RXA-16.1	Time	20180523
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20180504	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	49	Value-Test Case Fixed
RXA-5.2	Text	Hib	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	7M53K5535
RXA-16	Substance Expiration Date
RXA-16.1	Time	20181014
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170514	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	10	Value-Test Case Fixed
RXA-5.2	Text	Polio (IPV)	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D333PV2444
RXA-16	Substance Expiration Date
RXA-16.1	Time	20181004
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170721	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	10	Value-Test Case Fixed
RXA-5.2	Text	Polio (IPV)	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D333PV4343
RXA-16	Substance Expiration Date
RXA-16.1	Time	20180323
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20171015	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	10	Value-Test Case Fixed
RXA-5.2	Text	Polio (IPV)	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D333PV4343
RXA-16	Substance Expiration Date
RXA-16.1	Time	20180222
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	MSanofi Pasteur Inc.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170518	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	133	Value-Test Case Fixed
RXA-5.2	Text	Pneumococcal conjugate (PCV13)	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	P243V3321
RXA-16	Substance Expiration Date
RXA-16.1	Time	20180130
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170721	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	133	Value-Test Case Fixed
RXA-5.2	Text	Pneumococcal conjugate (PCV13)	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	P343V8445
RXA-16	Substance Expiration Date
RXA-16.1	Time	20180330
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170927
RXA-5	Administered Code
RXA-5.1	Identifier	133	Value-Test Case Fixed
RXA-5.2	Text	Pneumococcal conjugate (PCV13)	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	P853V2175
RXA-16	Substance Expiration Date
RXA-16.1	Time	20180830
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20180504	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	133	Value-Test Case Fixed
RXA-5.2	Text	Pneumococcal conjugate (PCV13)	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	P853V58544
RXA-16	Substance Expiration Date
RXA-16.1	Time	20181018
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PFR
RXA-17.2	Text	Pfizer, Inc
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170518	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	119	Value-Test Case Fixed
RXA-5.2	Text	Rotavirus	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6359RV543
RXA-16	Substance Expiration Date
RXA-16.1	Time	20171029
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170921	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	119	Value-Test Case Fixed
RXA-5.2	Text	Rotavirus	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6359RV933
RXA-16	Substance Expiration Date
RXA-16.1	Time	20180510
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20170927	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	161	Value-Test Case Fixed
RXA-5.2	Text	Influenza	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D8043IN8738
RXA-16	Substance Expiration Date
RXA-16.1	Time	20180312
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20171020	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	161	Value-Test Case Fixed
RXA-5.2	Text	Influenza	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D8043IN8798
RXA-16	Substance Expiration Date
RXA-16.1	Time	20180522
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC
RXA-17.2	Text	Sanofi Pasteur
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031	Presence-Content Indifferent
RXA-5	Administered Code
RXA-5.1	Identifier	49281-0413-58	Value-Test Case Fixed
RXA-5.2	Text	FLUZONE QUADRIVALENT	Presence-Content Indifferent
RXA-5.3	Name of Coding System	NDC	Value-Test Case Fixed
RXA-6	Administered Amount	0.25	Value-Test Case Fixed
RXA-7	Administered Units
RXA-7.1	Identifier	mL	Value-Test Case Fixed
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM	Value-Test Case Fixed
RXA-9	Administration Notes
RXA-9.1	Identifier	00	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina	Presence-Content Indifferent
RXA-10.3	Given Name	Sandra	Presence-Content Indifferent
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	D8043IN8855	Value-Test Case Fixed
RXA-16	Substance Expiration Date
RXA-16.1	Time	20191231	Value-Test Case Fixed
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	PMC	Value-Test Case Fixed
RXA-17.2	Text	Sanofi Pasteur	Presence-Content Indifferent
RXA-17.3	Name of Coding System	MVX	Value-Test Case Fixed
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP	Value-Test Case Fixed
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20180620	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	03	Value-Test Case Fixed
RXA-5.2	Text	measles, mumps, rubella virus vaccine	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Martinez
RXA-10.3	Given Name	J.
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	7W27V7632
RXA-16	Substance Expiration Date
RXA-16.1	Time	20191215
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	MSD
RXA-17.2	Text	Merck Sharp and Dohme Corp.
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031	Presence-Content Indifferent
RXA-5	Administered Code
RXA-5.1	Identifier	21	Value-Test Case Fixed
RXA-5.2	Text	varicella	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999	Value-Test Case Fixed
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier		Indifferent
RXA-9.2	Text
RXA-9.3	Name of Coding System		Indifferent
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname		Indifferent
RXA-10.3	Given Name		Indifferent
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time		Indifferent
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier		Indifferent
RXA-17.2	Text		Indifferent
RXA-17.3	Name of Coding System		Indifferent
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA	Value-Test Case Fixed
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031	Presence-Content Indifferent
RXA-5	Administered Code
RXA-5.1	Identifier	85	Value-Test Case Fixed
RXA-5.2	Text	Hep A, pediatric, unspecified formulation	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999	Value-Test Case Fixed
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier		Indifferent
RXA-9.2	Text
RXA-9.3	Name of Coding System		Indifferent
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA	A

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data	Categorization
RXR-1	Route
RXR-1.1	Identifier	C28161	Value-Test Case Fixed
RXR-1.2	Text	Intramuscular	Presence-Content Indifferent
RXR-1.3	Name of Coding System	NCIT	Value-Test Case Fixed
RXR-2	Administration Site
RXR-2.1	Identifier	LD	Value-Test Case Fixed
RXR-2.2	Text	Left Deltoid	Presence-Content Indifferent
RXR-2.3	Name of Coding System	HL70163	Value-Test Case Fixed

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Thigh Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	RT
RXR-2.2	Text	Right Thigh
RXR-2.3	Name of Coding System	HL70163

RXR : Pharmacy/Treatment Route

Location	Data Element	Data	Categorization
RXR-1	Route
RXR-1.1	Identifier	C28161	Value-Test Case Fixed
RXR-1.2	Text	Intramuscular	Presence-Content Indifferent
RXR-1.3	Name of Coding System	NCIT	Value-Test Case Fixed
RXR-2	Administration Site
RXR-2.1	Identifier	LD	Value-Test Case Fixed
RXR-2.2	Text	Left Deltoid	Presence-Content Indifferent
RXR-2.3	Name of Coding System	HL70163	Value-Test Case Fixed

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C38299
RXR-1.2	Text	Subcutaneous
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	1
OBX-2	Value Type	TS	Value-Test Case Fixed
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9	Value-Test Case Fixed
OBX-3.2	Text	Date vaccine information statement published	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Time	20150715	Value-Test Case Fixed
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7	Value-Test Case Fixed
OBX-3.2	Text	Date vaccine information statement presented	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Time	20181031	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE	Value-Test Case Fixed
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7	Value-Test Case Fixed
OBX-3.2	Text	vaccine fund pgm elig cat	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V01	Value-Test Case Fixed
OBX-5.2	Text	Not VFC elig	Presence-Content Indifferent
OBX-5.3	Name of Coding System	HL70064	Value-Test Case Fixed
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	4
OBX-2	Value Type	CE	Value-Test Case Fixed
OBX-3	Observation Identifier
OBX-3.1	Identifier	30963-3	Value-Test Case Fixed
OBX-3.2	Text	Vaccine funding source	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	PHC70	Presence-Content Indifferent
OBX-5.2	Text	Private
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	5
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7	Value-Test Case Fixed
OBX-3.2	Text	vaccine type	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	08	Value-Test Case Fixed
OBX-5.2	Text	Hepatitis B	Presence-Content Indifferent
OBX-5.3	Name of Coding System	CVX	Value-Test Case Fixed
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	1
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9	Value-Test Case Fixed
OBX-3.2	Text	VIS Publication Date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20140819	Value-Test Case Fixed
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7	Value-Test Case Fixed
OBX-3.2	Text	VIS Presentation Date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20181031	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	3
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7	Value-Test Case Fixed
OBX-3.2	Text	vaccine fund pgm elig cat	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V01	Value-Test Case Fixed
OBX-5.2	Text	Not VFC elig	Presence-Content Indifferent
OBX-5.3	Name of Coding System	HL70064	Value-Test Case Fixed
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30963-3
OBX-3.2	Text	Vaccine funding source
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	PHC70
OBX-5.2	Text	Private
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE	Value-Test Case Fixed
OBX-3	Observation Identifier
OBX-3.1	Identifier	59784-9	Value-Test Case Fixed
OBX-3.2	Text	Disease with presumed immunity	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	38907003	Value-Test Case Fixed
OBX-5.2	Text	History of Varicella infection	Presence-Content Indifferent
OBX-5.3	Name of Coding System	SCT	Value-Test Case Fixed
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20171031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	75505-8	Value-Test Case Fixed
OBX-3.2	Text	Diseases with serological evidence of immunity	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	278971009	Value-Test Case Fixed
OBX-5.2	Text	Serology confirmed hepatitis A	Presence-Content Indifferent
OBX-5.3	Name of Coding System	SCT	Value-Test Case Fixed
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

Test Data Specification

Patient Information

Element	Data
Patient Name	Juan Marcel Marina
Mother's Maiden Name	Anita Morales
ID Number	123456 987633
Date/Time of Birth	03/04/2017 11:00
Administrative Sex	Male
Patient Address	4623 Standish Way Stamford CT 06903 USA
Local Number	(203)555-1213
Race	White
Ethnic Group	Hispanic or Latino
Multiple Birth Indicator	No
Birth Order

Immunization Registry Information

Element	Data
Immunization Registry Status	Active
Immunization Registry Status Effective Date	03/04/2017
Publicity Code	Reminder/recall - no calls
Publicity Code Effective Date	03/04/2017
Protection Indicator	No
Protection Indicator Effective Date

Guardian or Responsible Party

Element	Data
Name	Manuel Marcel Gonzales
Relationship	Father
Address	4623 Standish Way Stamford CT 06903
Phone Number	(203)555-1213

Vaccine Administration Information[*]

Vaccine Administration Information

Element	Data
Administered Vaccine	Hepatitis B
Date/Time Start of Administration	03/04/2017
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	6332FK34
Substance Expiration Date	12/14/2017
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Shoreline Hospital
Entered By	Lisa Sirtis
Ordered By	Jane Carter

Vaccine Administration Information

Element	Data
Administered Vaccine	Hepatitis B
Date/Time Start of Administration	04/15/2017
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	6352FK2
Substance Expiration Date	10/01/2017
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Hepatitis B
Date/Time Start of Administration	10/31/2018
Administered Amount	0.5
Administered Units
Administration Notes
Administering Provider	Sandra Molina
Substance Lot Number	6332FK26
Substance Expiration Date	12/31/2019
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
Date vaccine information statement published	07/15/2015
Date vaccine information statement presented	10/31/2018
vaccine type	Hepatitis B

vaccine fund pgm elig cat	Not VFC elig
Vaccine funding source	Private

Vaccine Administration Information

Element	Data
Administered Vaccine	DTaP
Date/Time Start of Administration	05/15/2017
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D409QS2342
Substance Expiration Date	11/30/2018
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	DTaP
Date/Time Start of Administration	07/13/2017
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D409QS2434
Substance Expiration Date	09/04/2017
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	DTaP
Date/Time Start of Administration	09/16/2017
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D409QS250
Substance Expiration Date	12/01/2017
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	DTaP
Date/Time Start of Administration	08/20/2018
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D409QS250
Substance Expiration Date	03/01/2019
Substance Manufacturer Name	Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Hib
Date/Time Start of Administration	05/14/2017
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	7M54K9255
Substance Expiration Date	03/24/2018
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Hib
Date/Time Start of Administration	07/21/2017
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	7M55K3343
Substance Expiration Date	10/30/2017
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Hib
Date/Time Start of Administration	09/27/2017
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	7M75K4577
Substance Expiration Date	05/23/2018
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Hib
Date/Time Start of Administration	05/04/2018
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	7M53K5535
Substance Expiration Date	10/14/2018
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Polio (IPV)
Date/Time Start of Administration	05/14/2017
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D333PV2444
Substance Expiration Date	10/04/2018
Substance Manufacturer Name	MSanofi Pasteur Inc.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Polio (IPV)
Date/Time Start of Administration	07/21/2017
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D333PV4343
Substance Expiration Date	03/23/2018
Substance Manufacturer Name	MSanofi Pasteur Inc.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Polio (IPV)
Date/Time Start of Administration	10/15/2017
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D333PV4343
Substance Expiration Date	02/22/2018
Substance Manufacturer Name	MSanofi Pasteur Inc.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Pneumococcal conjugate (PCV13)
Date/Time Start of Administration	05/18/2017
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	P243V3321
Substance Expiration Date	01/30/2018
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Pneumococcal conjugate (PCV13)
Date/Time Start of Administration	07/21/2017
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	P343V8445
Substance Expiration Date	03/30/2018
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Pneumococcal conjugate (PCV13)
Date/Time Start of Administration	09/27/2017
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	P853V2175
Substance Expiration Date	08/30/2018
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Pneumococcal conjugate (PCV13)
Date/Time Start of Administration	05/04/2018
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	P853V58544
Substance Expiration Date	10/18/2018
Substance Manufacturer Name	Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Rotavirus
Date/Time Start of Administration	05/18/2017
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	6359RV543
Substance Expiration Date	10/29/2017
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Rotavirus
Date/Time Start of Administration	09/21/2017
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	6359RV933
Substance Expiration Date	05/10/2018
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Thigh Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza
Date/Time Start of Administration	09/27/2017
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D8043IN8738
Substance Expiration Date	03/12/2018
Substance Manufacturer Name	Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	Influenza
Date/Time Start of Administration	10/20/2017
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	D8043IN8798
Substance Expiration Date	05/22/2018
Substance Manufacturer Name	Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Right Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	FLUZONE QUADRIVALENT
Date/Time Start of Administration	10/31/2018
Administered Amount	0.25
Administered Units
Administration Notes
Administering Provider	Sandra Molina
Substance Lot Number	D8043IN8855
Substance Expiration Date	12/31/2019
Substance Manufacturer Name	Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
VIS Publication Date	08/19/2014
VIS Presentation Date	10/31/2018
vaccine fund pgm elig cat	Not VFC elig
Vaccine funding source	Private

Vaccine Administration Information

Element	Data
Administered Vaccine	measles, mumps, rubella virus vaccine
Date/Time Start of Administration	06/20/2018
Administered Amount	999
Administered Units
Administration Notes
Administering Provider	J. Martinez
Substance Lot Number	7W27V7632
Substance Expiration Date	12/15/2019
Substance Manufacturer Name	Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Subcutaneous
Administration Site	Left Thigh
Entering Organization	Oceanview Pediatrics
Entered By	J. Martinez
Ordered By	J. Rodriguez

Vaccine Administration Information

Element	Data
Administered Vaccine	varicella
Date/Time Start of Administration	10/31/2018
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
Disease with presumed immunity	History of Varicella infection

Vaccine Administration Information

Element	Data
Administered Vaccine	Hep A, pediatric, unspecified formulation
Date/Time Start of Administration	10/31/2018
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
Diseases with serological evidence of immunity	Serology confirmed hepatitis A

3.3.2. Receive ACK Z23 from Immunization Registry

Test Step Type: TA_RESPONDER
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message.

Test Story

Description
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message.

Comments
No Comments

Pre-condition
A VXU message is generated by the EHR.

Post-Condition
The ACK Z23 is received by the EHR.

Test Objectives
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries.

Evaluation Criteria
The acknowledgement message is consumed by the system responsible for the content of the administration message without error.

Notes
Important note regarding the MSH-10 and MSA-2: The NIST acknowledgment message is predefined and is based on the VXU message. Most systems will automatically create the message control Identifier and may require it for importing, linking, and processing the ACK message. The NIST ACK test message can be modified such that MSA-2 matches MSH-10 of the VXU message generated by the system-under test.

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	NISTIISAPP
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	NISTIISFAC
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	NISTEHRAPP
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NISTEHRFAC
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20180224073734.034-0500
MSH-9	Message Type
MSH-9.1	Message Code	ACK
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	ACK
MSH-10	Message Control ID	NIST-IZ-AD-1.2_Receive_ACK_Z23
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z23
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	NISTIISFAC
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	NISTEHRFAC
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	NIST-IZ-AD-1.1_Send_V04_Z22

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

3.3.3. Transmit Delete from Bad Lot

Test Step Type: SUT_INITIATOR
The provider identifies that the vaccine administration of Hepatitis B for this visit was documented in error. The vaccine was not administered during the visit as the provider had received notification that the Hepatitis B vaccine lot 332FK26 had been identified as a bad lot, and no other lot was available from inventory. A delete notification for the Hepatitis B vaccination administered is transmitted to the Immunization Registry for Juan Marcel Marina.

Test Story

Description

The provider identifies that the vaccine administration of Hepatitis B for this visit was documented in error. The vaccine was not administered during the visit as the provider had received notification that the Hepatitis B vaccine lot 332FK26 had been identified as a bad lot, and no other lot was available from inventory. A delete notification for the Hepatitis B vaccination administered is transmitted to the Immunization Registry for Juan Marcel Marina.

Comments
No Comments

Pre-condition

The vaccinations for the visit have been administered.
The vaccination report (Z22) has been transmitted to the IIS, including the record of the Hepatitis B vaccination with lot 6332FK26.

Post-Condition
The EMR has recorded that the hepatitis B vaccination was from a bad lot. Juan Marcel Marina's record is updated to reflect that the immunization given with lot 6332FK26 is invalid. The Delete notification for this vaccination has been transmitted to the Immunization Registry.

Test Objectives

Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization.
a. NDC codes, CVX for immunizations

Support for delete functionality.

Evaluation Criteria

Verify that EMR can record the bad lot. Verify that the vaccination record for Juan Marcel Marina for the Hepatitis B vaccination given with lot 6332FK26 is marked as invalid.
Verify that a valid Delete notification is transmitted to the Immunization Registry for this vaccination: The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content.

Notes
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data	Categorization
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	Test EHR Application
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	X68
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NIST Test Iz Reg
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20180701082240-0500
MSH-9	Message Type
MSH-9.1	Message Code	VXU
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	VXU_V04
MSH-10	Message Control ID	NIST-IZ-001.00
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z22
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	IIPEHRFAC	Presence-Content Indifferent
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code	XX	Presence-Content Indifferent
MSH-22.10	Organization Identifier	100-1	Presence-Content Indifferent
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	IIPIISFAC	Presence-Content Indifferent
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code	XX	Presence-Content Indifferent
MSH-23.10	Organization Identifier	100-2	Presence-Content Indifferent

PID : Patient Identification

Location	Data Element	Data	Categorization
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales
PID-5.2	Given Name	Juan	Value-Test Case Fixed
PID-5.3	Second and Further Given Names or Initials Thereof	Marcel	Value-Test Case Fixed
PID-5.7	Name Type Code	L	Value-Test Case Fixed
PID-6	Mother's Maiden Name
PID-6.1	Family Name
PID-6.1.1	Surname	Morales
PID-6.7	Name Type Code	M
PID-7	Date/Time of Birth
PID-7.1	Time	201703041100	Value-Test Case Fixed
PID-8	Administrative Sex	M	Value-Test Case Fixed
PID-10	Race
PID-10.1	Identifier	2106-3	Value-Test Case Fixed
PID-10.2	Text	White	Value-Test Case Fixed
PID-10.3	Name of Coding System	CDCREC	Value-Test Case Fixed
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	4623 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford	Value-Test Case Fixed
PID-11.4	State or Province	CT	Value-Test Case Fixed
PID-11.5	Zip or Postal Code	06903	Value-Test Case Fixed
PID-11.6	Country	USA	Value-Test Case Fixed
PID-11.7	Address Type	L	Value-Test Case Fixed
PID-13	Phone Number - Home
PID-13.2	Telecommunication Use Code	PRN	Value-Test Case Fixed
PID-13.3	Telecommunication Equipment Type	CP	Value-Test Case Fixed
PID-13.4	Email Address
PID-13.6	Area/City Code	203	Value-Test Case Fixed
PID-13.7	Local Number	5551213	Value-Test Case Fixed
PID-22	Ethnic Group
PID-22.1	Identifier	2135-2	Value-Test Case Fixed
PID-22.2	Text	Hispanic or Latino	Value-Test Case Fixed
PID-22.3	Name of Coding System	CDCREC	Value-Test Case Fixed
PID-24	Multiple Birth Indicator
PID-25	Birth Order
PID-29	Patient Death Date and Time
PID-29.1	Time
PID-30	Patient Death Indicator

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina	Presence-Content Indifferent
ORC-10.3	Given Name	Sandra	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP	Presence-Content Indifferent
ORC-17.2	Text	Shoreline Pediatrics	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031	Presence-Content Indifferent
RXA-5	Administered Code
RXA-5.1	Identifier	08	Value-Test Case Fixed
RXA-5.2	Text	Hepatitis B	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00	Value-Test Case Fixed
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina
RXA-10.3	Given Name	Sandra
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6332FK26
RXA-16	Substance Expiration Date
RXA-16.1	Time	20191231
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	D	Value-Test Case Fixed

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LD
RXR-2.2	Text	Left Deltoid
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7
OBX-3.2	Text	vaccine fund pgm elig cat
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V01
OBX-5.2	Text	Not VFC elig
OBX-5.3	Name of Coding System	HL70064
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Identifier	08
OBX-5.2	Text	Hepatitis B
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9
OBX-3.2	Text	Date vaccine information statement published
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Time	20150715
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7
OBX-3.2	Text	Date vaccine information statement presented
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	2
OBX-5	Observation Value
OBX-5.1	Time	20181031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

Test Data Specification

Patient Information

Element	Data
Patient Name	Juan Marcel Gonzales
Mother's Maiden Name	Anita Morales
ID Number	123456 987633
Date/Time of Birth	03/04/2017 11:00
Administrative Sex	Male
Patient Address	4623 Standish Way Stamford CT 06903 USA
Local Number	(203)555-1213
Race	White
Ethnic Group	Hispanic or Latino
Multiple Birth Indicator	No
Birth Order

Vaccine Administration Information

Element	Data
Administered Vaccine	Hepatitis B
Date/Time Start of Administration	10/31/2018
Administered Amount	0.5
Administered Units
Administration Notes
Administering Provider	Sandra Molina
Substance Lot Number	6332FK26
Substance Expiration Date	12/31/2019
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Delete
Route	IM
Administration Site	Left Deltoid
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
vaccine fund pgm elig cat	Not VFC elig

vaccine type	Hepatitis B
Date vaccine information statement published	07/15/2015
Date vaccine information statement presented	10/31/2018

3.3.4. Receive ACK Z23 from Immunization Registry

Test Step Type: TA_RESPONDER
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message.

Test Story

Description
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message.

Comments
No Comments

Pre-condition
A VXU message is generated by the EHR.

Post-Condition
The ACK Z23 is received by the EHR.

Test Objectives
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries.

Evaluation Criteria
The acknowledgement message is consumed by the system responsible for the content of the administration message without error.

Notes
Important note regarding the MSH-10 and MSA-2: The NIST acknowledgment message is predefined and is based on the VXU message. Most systems will automatically create the message control Identifier and may require it for importing, linking, and processing the ACK message. The NIST ACK test message can be modified such that MSA-2 matches MSH-10 of the VXU message generated by the system-under test.

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	NISTIISAPP
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	NISTIISFAC
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	NISTEHRAPP
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NISTEHRFAC
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20180224073734.034-0500
MSH-9	Message Type
MSH-9.1	Message Code	ACK
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	ACK
MSH-10	Message Control ID	NIST-IZ-AD-1.2_Receive_ACK_Z23
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z23
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	NISTIISFAC
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	NISTEHRFAC
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	NIST-IZ-AD-1.1_Send_V04_Z22

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

4. Juana Mariela Gonzales Visit

Infant twin, Juana Mariela Gonzales visits the provider where her immunization history is retrieved from the registry and reconciled with the local information in the medical record to determine vaccines that are due. Vaccinations are deferred due to fever. The vaccine deferrals are reported to the immunization registry and a vaccine summary is available for the patient.

Test Story

Description

Comments

Pre-condition

Post-Condition

Test Objectives

Evaluation Criteria

Notes

4.1. Query the Registry for Juana Mariela Gonzales

EMR Generates a Z44 query to the Immunization Registry to retrieve the Evaluated History and Forecast for Juana Mariela Gonzales.

Test Story

Description

The EMR Generates a Z44 query to the Immunization Registry to retrieve the Evaluated History and Forecast for Juana Mariela Gonzales. Querying the registry will consist of the vendor creating Z44 messages for Juana Mariela Gonzales to be sent to the registry. The response will be processed as part of the 'Display, Reconcile, Import and Update Immunization Information' activity.

Comments
No Comments

Pre-condition
Juana Mariela Gonzales is entered as a patient in the EMR with complete Demographic data, Immunization History Data, and Clinical Data according to the steps in the Juana Mariela Gonzales Initial Data Load'

Post-Condition
A Z44 Query is generated and submitted to the Immunization Registry/Test tool, and a Z42 response is returned.

Test Objectives

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
No Note

4.1.1. Select Patient Juana Mariela Gonzales

Test Step Type: SUT_MANUAL
Select patient Juana Mariela Gonzales, Infant Twin, distinguishing the patient from other patients with similar demographics (twins).

Test Story

Description
Juana Mariela Gonzales is selected as the patient and her record is opened in the EMR.

Comments
No Comments

Pre-condition
Juana Mariela Gonzales Initial Data Load completed.

Post-Condition
Juana Mariela Gonzales is the active working patient in the EMR.

Test Objectives

Evaluation Criteria

Tester shall verify that the product can distinguish Juana Mariela Gonzales Morales from similar sounding names and her twin using all of the pediatric demographics:

Patient ID (previously listed as "Medicaid Number") - Vendor supplied
Patient ID: Assigning Authority ID (i.e., owning source)/Facility Name - Shoreline Pediatrics
Patient ID: Type (e.g., medical record number, IIS ID) - Vendor supplied
Patient Name: First - Juana
Patient Name: Middle - Mariela
Patient Name: Last - Gonzales
Patient Date of Birth - 10/01/2018
Birth Time - 11:00
Patient Gender (Administrative Sex) - F
Patient Multiple Birth Indicator - Yes
Patient Birth Order - 1
Responsible Person Name: First - Joanna
Responsible Person Name: Middle - Elena
Responsible Person Name: Last - Gonzales
Responsible Person Name: Relationship to Patient - Mother
Mother's Name: First - Joanna
Mother's Name: Middle - Elena
Mother's Name: Last - Gonzales
Mother's Name: Maiden Last - Morales
Patient Address: Street - 3321 Standish Way
Patient Address: City - Stamford
Patient Address: State - CT
Patient Address: Country - US
Patient Address: Zipcode - 06903
Patient Address: County of Residence - Fairfield
Race - White
Ethnicity - Hispanic or Latino
Birthing Facility Name (Birth Delivery Location Address BDL) - Stamford Regional Hospital 15 Atlantic Avenue, Stamford Connecticut 06903
Patient Birth State - CT
Patient Primary Language - English
Patient Telephone Number - (203) 555-1214
Patient Telephone Number Type (e.g., home, cell) - home
Patient E-mail Address -
Publicity Code- Reminder/recall - no calls (03 HL70215)
Protection Indicator - No
Protection Indicator Effective Date
Immunization Registry Status
Preferred Contact Method - Text

Notes

Patient last name from the hospital returned by the IIS is Morales (the mother's maiden name). The patient last name in the EMR should be Gonzales. This test verifies that the EMR can match the returned record despite the different last name.

4.1.2. Query Registry for vaccination history and forecast for Juana Mariela Gonzales

Test Step Type: SUT_INITIATOR
The EMR generates a Z44 query for immunization history and forecast correctly and without omission according to supplied test data.

Test Story

Description
The provider uses the EMR to query the Immunization Registry for an Evaluated History and Forecast based on information known to the Immunization Registry.

Comments
No Comments

Pre-condition

Juana Mariela Gonzales Initial Data Load is completed.

Juana Mariela Gonzales is the active working patient in the EMR.

Post-Condition
The Immunization Registry responds with Evaluated Vaccine History and Forecast for Juana Mariela Gonzales.

Test Objectives

Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (QBP/RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5).

Evaluation Criteria

Tester shall verify that the vendor can produce a valid Z44 query in accordance with the test data correctly and without omission.

Tester shall verify that the data in the message corresponds to the data in the EMR and contains all test data attributes supplied.

Notes
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20180515001020-0500
MSH-9	Message Type
MSH-9.1	Message Code	QBP
MSH-9.2	Trigger Event	Q11
MSH-9.3	Message Structure	QBP_Q11
MSH-10	Message Control ID	793543
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z44
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

QPD : Query Parameter Definition

Location	Data Element	Data	Categorization
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Gonzales	Value-Test Case Fixed
QPD-4.2	Given Name	Juana	Value-Test Case Fixed
QPD-4.3	Second and Further Given Names or Initials Thereof	Mariela	Value-Test Case Fixed
QPD-4.7	Name Type Code	L	Value-Test Case Fixed
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Morales	Value-Test Case Fixed
QPD-5.7	Name Type Code	M	Value-Test Case Fixed
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201810011100	Value-Test Case Fixed
QPD-7	Patient Sex	F	Value-Test Case Fixed
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way	Value-Test Case Fixed
QPD-8.2	Other Designation
QPD-8.3	City	Stamford	Value-Test Case Fixed
QPD-8.4	State or Province	CT	Value-Test Case Fixed
QPD-8.5	Zip or Postal Code	06903	Value-Test Case Fixed
QPD-8.6	Country
QPD-8.7	Address Type	L	Value-Test Case Fixed
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN	Value-Test Case Fixed
QPD-9.3	Telecommunication Equipment Type	CP	Value-Test Case Fixed
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203	Value-Test Case Fixed
QPD-9.7	Local Number	5551214	Value-Test Case Fixed
QPD-10	Multiple birth indicator		Indifferent
QPD-11	Birth order		Indifferent

RCP : Response Control Parameter

Location	Data Element	Data
RCP-1	Query Priority	I
RCP-2	Quantity Limited Request
RCP-2.1	Quantity	1
RCP-2.2	Units
RCP-2.2.1	Identifier	RD
RCP-2.2.2	Text	Records
RCP-2.2.3	Name of Coding System	HL70126

Test Data Specification

Patient Information

Element	Data
Patient Name	Juana Mariela Gonzales
Mother's Maiden Name	Morales
ID Number
Date/Time of Birth	10/01/2018 11:00
Sex	Female
Patient Address	3321 Standish Way Stamford CT 06903
Patient Phone	(203)555-1214
Birth Indicator	No
Birth Order

4.1.3. View and import response to request for vaccination history for Juana Mariela Gonzales

Test Step Type: TA_RESPONDER
The EMR displays the Immunization History results (Z42) returned in response to the Z44 Query and import them into the EMR.

Test Story

Description

The physician accesses the record for Juana Mariela Gonzales and:

- Accepts the single vaccine in the registry record into the EHR history

Comments
There is no reconciliation step as there are no historical immunizations in the EMR. All will be imported from the Z42 response.

Pre-condition
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import.

Post-Condition
Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juana Mariela Gonzales)

Test Objectives

Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry.

Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5).

Evaluation Criteria

1. The EMR displays the information returned from the Immunization Registry according to the Juror Document.

2. The user imports returned vaccinations as follows:

a. Vaccinations Imported:

hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 10/1/2018

Notes

If the EMR is unable to match and import the previous immunization record, they will need to add the following historical immunization manually:

Vaccine from Practice HepB
Entered BY	Susan Pike	Y
Ordering Provider	Justin Parker	Y
Entering Organization	Shoreline Hospital	Y
Administration Notes (Vaccine Event information source)	New immunization record (NIP001 00)	Y
Date/Time of Start of Administration	10/01/2018	Y
Vaccine Administered	hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08, NDC 58160-0820-01)	Y
Administered Amount (of Vaccine)	0.5	Y
Administered Units (of Measure)	mL	Y
Administering Provider	Susan Pike	Y
Administered-at Location	15 Atlantic Avenue, Stamford, CT, 06903	Y
Lot Number	6332FK34	Y
Substance Expiration Date	12/14/2018	Y
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA (MVX SKB)	Y
Completion Status	Completed (CP)	Y
Route of Administration	Intramuscular (NCIT C28161, HL70162: IM)	Y
Administration Site	Left Thigh (HL70163 LT)	Y

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20181130020020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	793543

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	37374859
QAK-2	Query Response Status	OK
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Gonzales
QPD-4.2	Given Name	Juana
QPD-4.3	Second and Further Given Names or Initials Thereof	Mariela
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Morales
QPD-5.7	Name Type Code	M
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201810011100
QPD-7	Patient Sex	F
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code	06903
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	CP
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551214
QPD-10	Multiple birth indicator
QPD-11	Birth order

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales
PID-5.2	Given Name	Juana
PID-5.3	Second and Further Given Names or Initials Thereof	Mariela
PID-5.7	Name Type Code	L
PID-7	Date/Time of Birth
PID-7.1	Time	201810011100
PID-8	Administrative Sex	F
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	3321 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Stamford Regional Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181001
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Pike
RXA-10.3	Given Name	Susan
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	Hep B, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	Hep B, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20171201
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	DTaP, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	152
OBX-5.2	Text	Pneumococcal Conjugate, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20190901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20190901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20191001
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20191001
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20201002
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20191001
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20191001
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200101
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20191001
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20191001
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200101
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

Juror Document

Evaluated Immunization History and Immunization Forecast

Test Case ID

Query the Registry for Juana Mariela Gonzales

Inspection Settlement (Pass/Fail)

Pass	Fail

Reason Failed

Juror Comments

DISPLAY VERIFICATION

The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.

Patient Information
Element Name	Data	Tester Comment
Patient Identifier
ID Number	123456
Assigning Authority
Namespace ID	MYEHR
ID Type	MR
Patient Identifier
ID Number	987633
Assigning Authority
Namespace ID	MYIIS
ID Type	SR
Name	Juana Mariela Gonzales
Date of Birth	10/01/2018
Sex	Female
Address 1
Street	3321 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country	USA
Address Type	L
Mother's Maiden Name	Joanna Elena Morales
When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient.

Evaluated Immunization History Information
Element Name	Data	Tester Comment
Entering Organization	Stamford Regional Hospital
Vaccine Group	Hep B, unspecified formulation
Vaccine Administered	Hepatitis B
Refusal Reason
Date/Time Administration-Start	10/01/2018
Date/Time Administration-End	10/01/2018
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes
Administering Provider
Name	Susan Pike
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	15 Atlantic Avenue
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

* "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered".

Immunization Forecast
Element Name	Data	Tester Comment
Vaccine Group	Hep B, unspecified formulation
Vaccine Due Date	10/31/2018
Earliest Date to Give	10/31/2018
Latest Date to Give
Date When Vaccine Overdue	12/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	DTaP, unspecified formulation
Vaccine Due Date	11/30/2018
Earliest Date to Give	11/30/2018
Latest Date to Give
Date When Vaccine Overdue	10/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Hib
Vaccine Due Date	11/30/2018
Earliest Date to Give	11/30/2018
Latest Date to Give
Date When Vaccine Overdue	10/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	IPV
Vaccine Due Date	11/30/2018
Earliest Date to Give	11/30/2018
Latest Date to Give
Date When Vaccine Overdue	10/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Pneumococcal Conjugate, unspecified formulation
Vaccine Due Date	11/30/2018
Earliest Date to Give	11/30/2018
Latest Date to Give
Date When Vaccine Overdue	10/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	rotavirus, unspecified formulation
Vaccine Due Date	11/30/2018
Earliest Date to Give	11/30/2018
Latest Date to Give
Date When Vaccine Overdue	10/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	influenza, unspecified formulation
Vaccine Due Date	09/01/2019
Earliest Date to Give	09/01/2019
Latest Date to Give
Date When Vaccine Overdue	10/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Hep A, unspecified formulation
Vaccine Due Date	10/01/2019
Earliest Date to Give	10/01/2019
Latest Date to Give
Date When Vaccine Overdue	10/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	MMR
Vaccine Due Date	10/01/2019
Earliest Date to Give	10/01/2019
Latest Date to Give
Date When Vaccine Overdue	01/01/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Varicella
Vaccine Due Date	10/01/2019
Earliest Date to Give	10/01/2019
Latest Date to Give
Date When Vaccine Overdue	01/01/2020
Status in Immunization Series
Forecast Reason

4.1.4. View the vaccination forecast for Juana Mariela Gonzales

Test Step Type: SUT_MANUAL
The EMR displays the current Immunization Forecast to the user for Juana Mariela Gonzales either as returned by the IIS in prior step, or as generated thru any local means.

Test Story

Description

The physician accesses the record for Juana Mariela Gonzales and:

- Views the vaccine forecast (either as provided by the Immunization Registry or as determined through EMR defined methods)

Comments
No Comments

Pre-condition
EMR Vaccine History is imported from the Immunization History returned from the Immunization Registry (previous step 'View and import response to request for vaccination history for Juana Mariela Gonzales)

Post-Condition
A vaccine forecast based upon the imported vaccine history is available to the user.

Test Objectives

Evaluation Criteria

1. Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history:
2. Verify that the EMR includes in the vaccine forecast:

Hep B Peds NOS due on 10/31/2018
DTaP due on 11/30/2018
Hib due on 11/30/2018

IPV due on 11/30/2018

Pneumococcal conjugate due on 11/30/2018
Rotavirus due on 11/30/2018
HepA due on 10/1/2019
MMR due on 10/1/2019

Varicella due on 10/1/2019

influenza, unspecified formulation due on Sept 1, 2019 or later

Notes

The due date must be in range for the date shown. Vaccine forecast dates may be plus or minus 10 days to accommodate differences in date handling.

Further variation should be documented in the notable exceptions, but minimally each forecast vaccine must be present.

4.2. Juana Mariela Gonzales, Enter Orders and Immunizations

Orders and Immunization events, non-administrations, and alerts presented for current visit.

Test Story

Description
This test will consist of ordering vaccines for the test patients, reviewing any alerts caused by specific scenarios, and documenting vaccinations administered to the patients.

Comments
No Comments

Pre-condition
Juana Mariela Gonzales is entered as a patient in the EMR with complete Demographic data, Immunization History Data, and Clinical Data according to the steps in the 'Juana Mariela Gonzales Initial Data Load'

Post-Condition
Visit orders are entered in Juana Mariela Gonzales' record.

Test Objectives

Supporting data for documenting contraindications (it could also trigger an alert as a locally configured alert rule)

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
No Note

4.2.1. Enter Initial Clinical Information for Juana Mariela

Test Step Type: SUT_MANUAL
The EHR captures structured data indicating that Juana Mariela has a fever in the current visit.

Test Story

Description
The triage nurse enters basic information on Juana Mariela Gonzales - she has a fever (Temperature of 100.8^o F).

Comments
No Comments

Pre-condition
The EMR has recorded all of the pediatric demographic data in the record created for Juana Mariela Gonzales.

Post-Condition
The clinical record for Juana Mariela Gonzales indicates that she currently has a fever (temperature 100.8^oF).

Test Objectives

Supporting data for documenting contraindications (it could also trigger an alert as a locally configured alert rule):

Modify Antigen Recommendations Based on Active Diagnoses: The system notifies the provider of any conflicts between recommended vaccines in the updated forecast and the patient's current or historical diagnoses.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all clinical data provided with all required attributes indicated by [Y]. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:

Vital Signs	Fever of 100.8 (@code LOINC 8310-5 @value 100.8)
Vital Signs Observation Date	Date of current visit
Problems (If vendor uses problems for alert computations, then this should be included.)	Problem list: ( Low grade pyrexia (finding) 304213008)
Problem Observation Date	Date of current visit

Notes
No Note

4.2.2. Enters a deferral for the vaccines due

Test Step Type: SUT_MANUAL
Enters a deferral for vaccines due (Hepatitis B, DTaP, Hib, Pneumococcal conjugate (PCV13) and Rotavirus) due to medical reason, indicating low grade fever, and defers for 1 month.

Test Story

Description
The physician accesses the record for Juana Mariela Gonzales Morales and: - Enters a deferral for the vaccines due (Hepatitis B, DTaP, Hib, Pneumococcal conjugate (PCV13) and Rotavirus) due to medical reason, indicating low grade fever, and defers for 1 month

Comments
No Comment

Pre-condition
Prior Immunization History loaded and reconciled from the Immunization Registry. Vaccine forecast is available in the EMR indicating 5 vaccines are due: Hepatitis B, DTaP, Hib, Pneumococcal conjugate (PCV13) and Rotavirus

Post-Condition
Vaccine deferral is recorded indicating the medical reason of low grade fever

Test Objectives
Record Vaccine Administration Deferral: The EHR or other clinical software system allows a user to enter a reason or reasons why a specific immunization was not given to a patient (e.g., due to contraindication, refusal, etc.). The system also stores that information in a structured way so it can be reported and analyzed as needed.

Evaluation Criteria

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source	New immunization record (NIP001 00)
Value/Text for Vaccine Type	hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) pneumococcal conjugate vaccine, 13 valent (CVX 133) rotavirus, live, monovalent vaccine (CVX 119)
Date/Time Vaccine not administered was recorded	Current Date
Alert	contraindication of fever
Substance/Treatment Deferral Start Date:Vaccination contraindication/precaution effective date (30946-8 LOINC)	Current Date
Substance/Treatment Deferral End Date/Vaccination temporary contraindication/precaution expiration date (30944-3 LOINC) :	Current Date +30 Days
Substance/Treatment Deferral Contraindication: Vaccination contraindication/precaution (30945-0 LOINC):	current fever with moderate-to-severe illness (PHVS_VaccinationContraindication_IIS - VXC23)
Completion Status:	NA
Date/Time Vaccine Deferral was recorded:	Current Date

Notes
The EMR does not need to specify a 'new immunization', as long as there is a way to indicate that it is a new immunization within the EMR, this is acceptable (e.g. the default interpretation of the data entry is that it is a new immunization and not historical).

4.3. Juana Mariela Gonzales Transmit Immunization Report

Send the Immunization Report to the Immunization Registry (VXU/Z22) for Juana Mariela Gonzales.

Test Story

Description
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes deferrals for the vaccines that were due this visit indicating the medical reason. The report MAY send the immunizations that the EMR imported from the IIS.

Comments
No Comments

Pre-condition
The vaccines for the visit have been deferred.

Post-Condition
The IIS has received the vaccine information (Z22 message).

Test Objectives

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
No Note

4.3.1. Transmit the Immunization Report for Juana Mariela Gonzales

Test Step Type: SUT_INITIATOR
The EMR sends the Immunization Report to the Immunization Registry (VXU/Z22) for updated vaccination information from the visit. This includes the vaccine deferral and may include historical information updated in the EMR during the visit.

Test Story

Description
Following the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes the vaccine deferrals. The report MAY send the immunizations that the EMR imported from the IIS.

Comments
The Report must include all vaccine deferrals recorded in the EMR in any order. The report may include the information imported from the IIS

Pre-condition
The vaccines for the visit have been administered.

Post-Condition
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission.

Test Objectives

Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization.
a. NDC codes, CVX for immunizations

Evaluation Criteria
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. The message must contain all deferrals recorded in the EMR. Current Date is expected for the Non-Administration date and deferral date.

Notes
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data	Categorization
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	Test EHR Application
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	X68
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NIST Test Iz Reg
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20180701082240-0500
MSH-9	Message Type
MSH-9.1	Message Code	VXU
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	VXU_V04
MSH-10	Message Control ID	NIST-IZ-001.00
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z22
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	IIPEHRFAC	Presence-Content Indifferent
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code	XX	Presence-Content Indifferent
MSH-22.10	Organization Identifier	100-1	Presence-Content Indifferent
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	IIPIISFAC	Presence-Content Indifferent
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code	XX	Presence-Content Indifferent
MSH-23.10	Organization Identifier	100-2	Presence-Content Indifferent

PID : Patient Identification

Location	Data Element	Data	Categorization
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales	Value-Test Case Fixed
PID-5.2	Given Name	Juana	Value-Test Case Fixed
PID-5.3	Second and Further Given Names or Initials Thereof	Mariela	Value-Test Case Fixed
PID-5.7	Name Type Code	L	Value-Test Case Fixed
PID-6	Mother's Maiden Name
PID-6.1	Family Name
PID-6.1.1	Surname	Morales	Value-Test Case Fixed
PID-6.7	Name Type Code	M	Value-Test Case Fixed
PID-7	Date/Time of Birth
PID-7.1	Time	201810011100	Value-Test Case Fixed
PID-8	Administrative Sex	F	Value-Test Case Fixed
PID-10	Race
PID-10.1	Identifier	2106-3	Value-Test Case Fixed
PID-10.2	Text	White	Value-Test Case Fixed
PID-10.3	Name of Coding System	CDCREC	Value-Test Case Fixed
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	3321 Standish Way	Value-Test Case Fixed
PID-11.2	Other Designation
PID-11.3	City	Stamford	Value-Test Case Fixed
PID-11.4	State or Province	CT	Value-Test Case Fixed
PID-11.5	Zip or Postal Code	06903	Value-Test Case Fixed
PID-11.6	Country	USA	Value-Test Case Fixed
PID-11.7	Address Type	L	Value-Test Case Fixed
PID-13	Phone Number - Home
PID-13.2	Telecommunication Use Code	PRN	Value-Test Case Fixed
PID-13.3	Telecommunication Equipment Type	CP	Value-Test Case Fixed
PID-13.4	Email Address
PID-13.6	Area/City Code	203	Value-Test Case Fixed
PID-13.7	Local Number	5551212	Value-Test Case Fixed
PID-22	Ethnic Group
PID-22.1	Identifier	2135-2	Value-Test Case Fixed
PID-22.2	Text	Hispanic or Latino	Value-Test Case Fixed
PID-22.3	Name of Coding System	CDCREC	Value-Test Case Fixed
PID-24	Multiple Birth Indicator	Y	Value-Test Case Fixed
PID-25	Birth Order	1	Value-Test Case Fixed
PID-29	Patient Death Date and Time
PID-29.1	Time
PID-30	Patient Death Indicator

PD1 : Patient Additional Demographic

Location	Data Element	Data	Categorization
PD1-11	Publicity Code
PD1-11.1	Identifier	03	Value-Test Case Fixed
PD1-11.2	Text	Reminder/recall - no calls	Presence-Content Indifferent
PD1-11.3	Name of Coding System	HL70215	Value-Test Case Fixed
PD1-12	Protection Indicator	Y	Value-Test Case Fixed
PD1-13	Protection Indicator Effective Date
PD1-16	Immunization Registry Status	A
PD1-17	Immunization Registry Status Effective Date	20181001	Presence-Content Indifferent
PD1-18	Publicity Code Effective Date	20181001	Presence-Content Indifferent

NK1 : Next of Kin / Associated Parties

Location	Data Element	Data	Categorization
NK1-1	Set ID - NK1	1
NK1-2	Name
NK1-2.1	Family Name
NK1-2.1.1	Surname	Gonzales	Value-Test Case Fixed
NK1-2.2	Given Name	Joanna	Value-Test Case Fixed
NK1-2.3	Second and Further Given Names or Initials Thereof	Elena	Value-Test Case Fixed
NK1-2.7	Name Type Code	L	Value-Test Case Fixed
NK1-3	Relationship
NK1-3.1	Identifier	MTH	Value-Test Case Fixed
NK1-3.2	Text	Mother	Presence-Content Indifferent
NK1-3.3	Name of Coding System	HL70063	Value-Test Case Fixed
NK1-4	Address
NK1-4.1	Street Address
NK1-4.1.1	Street or Mailing Address	3321 Standish Way	Indifferent
NK1-4.2	Other Designation
NK1-4.3	City	Stamford	Indifferent
NK1-4.4	State or Province	CT	Indifferent
NK1-4.5	Zip or Postal Code	06903	Indifferent
NK1-4.6	Country
NK1-4.7	Address Type	L	Indifferent
NK1-5	Phone Number
NK1-5.2	Telecommunication Use Code	PRN	Indifferent
NK1-5.3	Telecommunication Equipment Type	PH	Indifferent
NK1-5.4	Email Address
NK1-5.6	Area/City Code	203	Indifferent
NK1-5.7	Local Number	5551214	Indifferent

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Sirtis
ORC-10.3	Given Name	Lisa
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Carter
ORC-12.3	Given Name	Jane
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Shoreline Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Molina
ORC-10.3	Given Name	Sandra
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Smith
ORC-12.3	Given Name	Frank
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SP
ORC-17.2	Text	Shoreline Pediatrics
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181001	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	08	Value-Test Case Fixed
RXA-5.2	Text	Hepatitis B	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	08
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Pike
RXA-10.3	Given Name	Susan
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6332FL432
RXA-16	Substance Expiration Date
RXA-16.1	Time	20181214
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031	Presence-Content Indifferent
RXA-5	Administered Code
RXA-5.1	Identifier	45	Value-Test Case Fixed
RXA-5.2	Text	hepatitis B vaccine, unspecified formulation	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999	Value-Test Case Fixed
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031	Presence-Content Indifferent
RXA-5	Administered Code
RXA-5.1	Identifier	107	Value-Test Case Fixed
RXA-5.2	Text	DTaP, unspecified formulation	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031	Presence-Content Indifferent
RXA-5	Administered Code
RXA-5.1	Identifier	49	Value-Test Case Fixed
RXA-5.2	Text	Hib	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999	Value-Test Case Fixed
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031	Presence-Content Indifferent
RXA-5	Administered Code
RXA-5.1	Identifier	152	Value-Test Case Fixed
RXA-5.2	Text	Pneumococcal Conjugate, unspecified formulation	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999	Value-Test Case Fixed
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA	A

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031	Presence-Content Indifferent
RXA-5	Administered Code
RXA-5.1	Identifier	122	Value-Test Case Fixed
RXA-5.2	Text	rotavirus, unspecified formulation	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	999	Value-Test Case Fixed
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number
RXA-16	Substance Expiration Date
RXA-16.1	Time
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA
RXA-21	Action Code - RXA	A

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	Intramuscular
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30945-0	Value-Test Case Fixed
OBX-3.2	Text	Vaccination contraindication	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC23	Indifferent
OBX-5.2	Text	current fever with moderate-to-severe illness	Presence-Content Indifferent
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30946-8	Value-Test Case Fixed
OBX-3.2	Text	Vaccination contraindication/precaution effective date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20181201	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181201
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	3
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30944-3	Value-Test Case Fixed
OBX-3.2	Text	Vaccination temporary contraindication/precaution expiration date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20180101	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181201
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30945-0	Value-Test Case Fixed
OBX-3.2	Text	Vaccination contraindication	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC23	Presence-Content Indifferent
OBX-5.2	Text	current fever with moderate-to-severe illness	Presence-Content Indifferent
OBX-5.3	Name of Coding System	CDCPHINVS	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30946-8	Value-Test Case Fixed
OBX-3.2	Text	Vaccination contraindication/precaution effective date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20181201	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181201	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	3
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30944-3	Value-Test Case Fixed
OBX-3.2	Text	Vaccination temporary contraindication/precaution expiration date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20180101	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181201
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30945-0	Value-Test Case Fixed
OBX-3.2	Text	Vaccination contraindication	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC23	Presence-Content Indifferent
OBX-5.2	Text	current fever with moderate-to-severe illness	Presence-Content Indifferent
OBX-5.3	Name of Coding System	CDCPHINVS	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30946-8	Value-Test Case Fixed
OBX-3.2	Text	Vaccination contraindication/precaution effective date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20181201	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181201	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	3
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30944-3	Value-Test Case Fixed
OBX-3.2	Text	Vaccination temporary contraindication/precaution expiration date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20180101	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181201	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30945-0	Value-Test Case Fixed
OBX-3.2	Text	Vaccination contraindication	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC23	Presence-Content Indifferent
OBX-5.2	Text	current fever with moderate-to-severe illness	Presence-Content Indifferent
OBX-5.3	Name of Coding System	CDCPHINVS	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30946-8	Value-Test Case Fixed
OBX-3.2	Text	Vaccination contraindication/precaution effective date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20181201	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181201	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	3
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30944-3	Value-Test Case Fixed
OBX-3.2	Text	Vaccination temporary contraindication/precaution expiration date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20180101	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181201	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30945-0	Value-Test Case Fixed
OBX-3.2	Text	Vaccination contraindication	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC23	Presence-Content Indifferent
OBX-5.2	Text	current fever with moderate-to-severe illness	Presence-Content Indifferent
OBX-5.3	Name of Coding System	CDCPHINVS	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30946-8	Value-Test Case Fixed
OBX-3.2	Text	Vaccination contraindication/precaution effective date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20181201	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181201	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	3
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	30944-3	Value-Test Case Fixed
OBX-3.2	Text	Vaccination temporary contraindication/precaution expiration date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20180101	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181201	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

Test Data Specification

Patient Information

Element	Data
Patient Name	Juana Mariela Gonzales
Mother's Maiden Name	Joanna Morales
ID Number	123456 987633
Date/Time of Birth	10/01/2018 11:00
Administrative Sex	Female
Patient Address	3321 Standish Way Stamford CT 06903 USA
Local Number	(203)555-1212
Race	White
Ethnic Group	Hispanic or Latino
Multiple Birth Indicator	Yes
Birth Order	1

Immunization Registry Information

Element	Data
Immunization Registry Status	Active
Immunization Registry Status Effective Date	10/01/2018
Publicity Code	Reminder/recall - no calls
Publicity Code Effective Date	10/01/2018
Protection Indicator	Yes
Protection Indicator Effective Date

Guardian or Responsible Party

Element	Data
Name	Joanna Elena Gonzales
Relationship	Mother
Address	3321 Standish Way Stamford CT 06903
Phone Number	(203)555-1214

Vaccine Administration Information[*]

Vaccine Administration Information

Element	Data
Administered Vaccine	Hepatitis B
Date/Time Start of Administration	10/01/2018
Administered Amount	0.5
Administered Units
Administration Notes
Administering Provider	Susan Pike
Substance Lot Number	6332FL432
Substance Expiration Date	12/14/2018
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Shoreline Hospital
Entered By	Lisa Sirtis
Ordered By	Jane Carter

Vaccine Administration Information

Element	Data
Administered Vaccine	hepatitis B vaccine, unspecified formulation
Date/Time Start of Administration	10/31/2018
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
Vaccination contraindication	current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date	12/01/2018
Vaccination temporary contraindication/precaution expiration date	01/01/2018

Vaccine Administration Information

Element	Data
Administered Vaccine	DTaP, unspecified formulation
Date/Time Start of Administration	10/31/2018
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
Vaccination contraindication	current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date	12/01/2018
Vaccination temporary contraindication/precaution expiration date	01/01/2018

Vaccine Administration Information

Element	Data
Administered Vaccine	Hib
Date/Time Start of Administration	10/31/2018
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
Vaccination contraindication	current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date	12/01/2018
Vaccination temporary contraindication/precaution expiration date	01/01/2018

Vaccine Administration Information

Element	Data
Administered Vaccine	Pneumococcal Conjugate, unspecified formulation
Date/Time Start of Administration	10/31/2018
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
Vaccination contraindication	current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date	12/01/2018
Vaccination temporary contraindication/precaution expiration date	01/01/2018

Vaccine Administration Information

Element	Data
Administered Vaccine	rotavirus, unspecified formulation
Date/Time Start of Administration	10/31/2018
Administered Amount	999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status	Not Administered
Action Code	Add
Route
Administration Site
Entering Organization	Shoreline Pediatrics
Entered By	Sandra Molina
Ordered By	Frank Smith

Element	Data
Vaccination contraindication	current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date	12/01/2018
Vaccination temporary contraindication/precaution expiration date	01/01/2018

4.3.2. Receive ACK Z23 from Immunization Registry

Test Step Type: TA_RESPONDER
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message.

Test Story

Description
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message.

Comments
No Comments

Pre-condition
A VXU message is generated by the EHR.

Post-Condition
The ACK Z23 is received by the EHR.

Test Objectives
No Test Objectives

Evaluation Criteria
The acknowledgement message is consumed by the system responsible for the content of the administration message without error.

Notes
Important note regarding the MSH-10 and MSA-2: The NIST acknowledgment message is predefined and is based on the VXU message. Most systems will automatically create the message control Identifier and may require it for importing, linking, and processing the ACK message. The NIST ACK test message can be modified such that MSA-2 matches MSH-10 of the VXU message generated by the system-under test.

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	NISTIISAPP
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	NISTIISFAC
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	NISTEHRAPP
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NISTEHRFAC
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20180224073734.034-0500
MSH-9	Message Type
MSH-9.1	Message Code	ACK
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	ACK
MSH-10	Message Control ID	NIST-IZ-AD-1.2_Receive_ACK_Z23
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z23
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	NISTIISFAC
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	NISTEHRFAC
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	NIST-IZ-AD-1.1_Send_V04_Z22

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

5. Juana Maria Gonzales Visit

Infant twin, Juana Maria Gonzales Morales visits the provider where her immunization history is retrieved from the registry and reconciled with the local information in the medical record to determine vaccines that are due. Vaccinations are ordered and administered. The vaccines are reported to the immunization registry and a vaccine summary is available for the patient.

Test Story

Description

Comments

Pre-condition

Post-Condition

Test Objectives

Evaluation Criteria

Notes

5.1. Query the Registry for Juana Maria Gonzales.

EMR Generates a Z44 query to the Immunization Registry to retrieve the Evaluated History and Forecast for Juana Maria Gonzales

Test Story

Description

The EMR Generates a Z44 query to the Immunization Registry to retrieve the Evaluated History and Forecast for Juana Maria Gonzales. Querying the registry will consist of the vendor creating Z44 messages for Juana Maria Gonzales to be sent to the registry. The response will be processed as part of the 'Display, Reconcile, Import and Update Immunization Information' activity.

Comments
No Comments

Pre-condition
Juana Mariela Gonzales is entered as a patient in the EMR with complete Demographic data, Immunization History Data, and Clinical Data according to the steps in the Juana Mariela Gonzales Initial Data Load

Post-Condition
A Z44 Query is generated and submitted to the Immunization Registry/Test tool, and a Z42 response is returned.

Test Objectives

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
No Note

5.1.1. Select Patient Juana Maria Gonzales

Test Step Type: SUT_MANUAL
Select patient Juana Maria Gonzales, Infant Twin, distinguishing the patient from other patients with similar demographics (twins).

Test Story

Description
Juana Maria Gonzales is selected as the patient and her record is opened in the EMR.

Comments
No Comments

Pre-condition
Juana Maria Gonzales Initial Data Load completed.

Post-Condition
Juana Maria Gonzales is the active working patient in the EMR.

Test Objectives

Evaluation Criteria

Tester shall verify that the product can distinguish Juana Maria Gonzales from similar sounding names and her twin using all of the pediatric demographics:

Patient ID (previously listed as "Medicaid Number") - Vendor supplied
Patient ID: Assigning Authority ID (i.e., owning source)/Facility Name - Shoreline Pediatrics
Patient ID: Type (e.g., medical record number, IIS ID) - Vendor supplied
Patient Name: First - Juana
Patient Name: Middle - Maria
Patient Name: Last - Gonzales
Patient Date of Birth - 10/01/2018
Birth Time - 11:15
Patient Gender (Administrative Sex) - F
Patient Multiple Birth Indicator - Yes
Patient Birth Order - 2
Responsible Person Name: First - Joanna
Responsible Person Name: Middle - Elena
Responsible Person Name: Last - Gonzales
Responsible Person Name: Relationship to Patient - Mother
Mother's Name: First - Joanna
Mother's Name: Middle - Elena
Mother's Name: Last - Gonzales
Mother's Name: Maiden Last - Morales
Patient Address: Street - 3321 Standish Way
Patient Address: City - Stamford
Patient Address: State - CT
Patient Address: Country - US
Patient Address: Zipcode - 06903
Patient Address: County of Residence - Fairfield
Race - White
Ethnicity - Hispanic or Latino
Birthing Facility Name (Birth Delivery Location Address BDL) - Stamford Regional Hospital 15 Atlantic Avenue, Stamford Connecticut 06903
Patient Birth State - CT
Patient Primary Language - English
Patient Telephone Number - (203) 555-1214
Patient Telephone Number Type (e.g., home, cell) - home
Patient E-mail Address -
Publicity Code- Reminder/recall - no calls (03 HL70215)
Protection Indicator
Protection Indicator Effective Date
Immunization Registry Status
Preferred Contact Method - Text

Notes
No Note

5.1.2. Query Registry for vaccination history and forecast too many matches found response

Test Step Type: SUT_INITIATOR
Vendor SHALL be able to Generate a Z44 Query correctly and without ommission according to supplied test data

Test Story

Description
The provider uses the EMR to query the Immunization Registry for an Evaluated History and Forecast based on information known to the Immunization Registry. This query will result in an error that too many matches are found.

Comments
While the query is identical, the response to this step will be that no persons are found. No demographic changes are requested for this step as the error trigger is specific to the test step.

Pre-condition

Juana Maria Gonzales Initial Data Load is completed.

Juana Maria Gonzales is the active working patient in the EMR.

Post-Condition
The Immunization Registry responds with Evaluated Vaccine History and Forecast for Juana Maria Gonzales.

Test Objectives

Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (QBP/RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5).

Setup step to test error handling: Test the capability of the EHR-S to process a response message that returns no persons found and to provide an indication to the end user.

Evaluation Criteria

Tester shall verify that the vendor can produce a valid Z44 query in accordance with the test data correctly and without omission.

Tester shall verify that the data in the message corresponds to the data in the EMR and contains all test data attributes supplied.

Notes
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20180515001020-0500
MSH-9	Message Type
MSH-9.1	Message Code	QBP
MSH-9.2	Trigger Event	Q11
MSH-9.3	Message Structure	QBP_Q11
MSH-10	Message Control ID	793543
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z44
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

QPD : Query Parameter Definition

Location	Data Element	Data	Categorization
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number	123456
QPD-3.4	Assigning Authority
QPD-3.5	Identifier Type Code	MR
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Gonzales	Value-Test Case Fixed
QPD-4.2	Given Name	Juana	Value-Test Case Fixed
QPD-4.3	Second and Further Given Names or Initials Thereof	Maria	Value-Test Case Fixed
QPD-4.7	Name Type Code	L	Value-Test Case Fixed
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Morales	Value-Test Case Fixed
QPD-5.7	Name Type Code	M	Value-Test Case Fixed
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201810011115	Value-Test Case Fixed
QPD-7	Patient Sex	F	Value-Test Case Fixed
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code	06903
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	CP
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551214
QPD-10	Multiple birth indicator	Y	Value-Test Case Fixed
QPD-11	Birth order	2	Value-Test Case Fixed

RCP : Response Control Parameter

Location	Data Element	Data
RCP-1	Query Priority	I
RCP-2	Quantity Limited Request
RCP-2.1	Quantity	1
RCP-2.2	Units
RCP-2.2.1	Identifier	RD
RCP-2.2.2	Text	Records
RCP-2.2.3	Name of Coding System	HL70126

Test Data Specification

Patient Information

Element	Data
Patient Name	Juana Maria Gonzales
Mother's Maiden Name	Morales
ID Number	123456
Date/Time of Birth	10/01/2018 11:15
Sex	Female
Patient Address	3321 Standish Way Stamford CT 06903
Patient Phone	(203)555-1214
Birth Indicator	Yes
Birth Order	2

5.1.3. Error Handling - Too many matches found

Test Step Type: TA_RESPONDER
The EMR receives a response from the registry query that too many persons are found. The EMR notifies the user/clinician.

Test Story

Description
The EMR processes notifies the user that there were too many matches found in response to the query the Immunization Registry for an Evaluated History and Forecast.

Comments
The sending (querying) system will need to accept a response indicating that too many matches were found.

Pre-condition
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import.

Post-Condition
The Immunization Registry responds with a message is indicating too many matches are found. The EMR has notified the user.

Test Objectives

Tests error handling: Test the capability of the EHR-S to process a response message that returns too many matches found and to provide an indication to the end user.

Evaluation Criteria

The tester verifies that the user/clinician is notified of no match.

The EHR shall display a notification indicating that the query for an Evaluated Immunization History and Immunization Forecast is complete but too many matching records were found for the person in the query.

Notes
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	NISTIISAPP
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	NISTIISFAC
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	NISTEHRAPP
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NISTEHRFAC
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20181031145233-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	NIST-IZ-QR-4.2_Response_TM_K11_Z33
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z33
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	NISTIISFAC
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code	XX
MSH-22.10	Organization Identifier	100-3322
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	NISTEHRFAC
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code	XX
MSH-23.10	Organization Identifier	100-6482

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	NIST-IZ-QR-3.1_Query_Q11_Z44

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	IZ-3.1-2015
QAK-2	Query Response Status	TM
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Gonzales
QPD-4.2	Given Name	Juana
QPD-4.3	Second and Further Given Names or Initials Thereof	Maria
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Morales
QPD-5.7	Name Type Code	M
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201810011115
QPD-7	Patient Sex	F
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code	06903
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	PH
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551214
QPD-10	Multiple birth indicator
QPD-11	Birth order

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

5.1.4. Query Registry for vaccination history and forecast no persons found response

Test Step Type: SUT_INITIATOR
Vendor SHALL be able to Generate a Z44 Query correctly and without ommission according to supplied test data

Test Story

Description
The provider uses the EMR to query the Immunization Registry for an Evaluated History and Forecast based on information known to the Immunization Registry. This query will result in an error that no persons are found.

Comments

This step is a repeat of Step 2: Query Registry for vaccination history and forecast for Juana Maria Gonzales in order to set up the error-checking response for 'No Persons Found'.

While the query is identical, the response to this step will be that no persons are found. No demographic changes are requested for this step as the error trigger is specific to the test step.

Pre-condition

Juana Maria Gonzales Initial Data Load is completed.

Juana Maria Gonzales is the active working patient in the EMR.

Post-Condition
The Immunization Registry responds with Evaluated Vaccine History and Forecast for Juana Maria Gonzales.

Test Objectives

Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (QBP/RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5).

Tests error handling: Test the capability of the EHR-S to process a response message that returns no persons found and to provide an indication to the end user.

Evaluation Criteria
Tester verifies that the message has been created and submitted in the test plan to trigger the error handling response in the next step.

Notes
Query step is the same as Step 2: Query Registry for vaccination history and forecast for Juana Maria Gonzales. No new requirements tested

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20180515001020-0500
MSH-9	Message Type
MSH-9.1	Message Code	QBP
MSH-9.2	Trigger Event	Q11
MSH-9.3	Message Structure	QBP_Q11
MSH-10	Message Control ID	793543
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z44
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

QPD : Query Parameter Definition

Location	Data Element	Data	Categorization
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number	123456
QPD-3.4	Assigning Authority
QPD-3.5	Identifier Type Code	MR
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Gonzales	Value-Test Case Fixed
QPD-4.2	Given Name	Juana	Value-Test Case Fixed
QPD-4.3	Second and Further Given Names or Initials Thereof	Maria	Value-Test Case Fixed
QPD-4.7	Name Type Code	L	Value-Test Case Fixed
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Morales	Value-Test Case Fixed
QPD-5.7	Name Type Code	M	Value-Test Case Fixed
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201810011115	Value-Test Case Fixed
QPD-7	Patient Sex	F	Value-Test Case Fixed
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code	06903
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	CP
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551214
QPD-10	Multiple birth indicator	Y	Value-Test Case Fixed
QPD-11	Birth order	2	Value-Test Case Fixed

RCP : Response Control Parameter

Location	Data Element	Data
RCP-1	Query Priority	I
RCP-2	Quantity Limited Request
RCP-2.1	Quantity	1
RCP-2.2	Units
RCP-2.2.1	Identifier	RD
RCP-2.2.2	Text	Records
RCP-2.2.3	Name of Coding System	HL70126

Test Data Specification

Patient Information

Element	Data
Patient Name	Juana Maria Gonzales
Mother's Maiden Name	Morales
ID Number	123456
Date/Time of Birth	10/01/2018 11:15
Sex	Female
Patient Address	3321 Standish Way Stamford CT 06903
Patient Phone	(203)555-1214
Birth Indicator	Yes
Birth Order	2

5.1.5. Error Handling - No persons found

Test Step Type: TA_RESPONDER
The EMR receives a response from the registry query that no persons are found. The EMR notifies the user/clinician.

Test Story

Description
The EMR processes notifies the user that there were no persons found in response to the query the Immunization Registry for an Evaluated History and Forecast.

Comments
The sending (querying) system will need to accept a response indicating that no matches were found.

Pre-condition
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import.

Post-Condition
The Immunization Registry responds with a message is indicating no person record is found. The EMR has notified the user.

Test Objectives

Tests error handling: Test the capability of the EHR-S to process a response message that returns no persons found and to provide an indication to the end user.

Evaluation Criteria

The tester verifies that the user/clinician is notified of no match.

The EHR shall display a notification indicating that the query for an Evaluated Immunization History and Immunization Forecast is complete but no matching records were found for the person in the query.

Notes
No Note

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	NISTIISAPP
MSH-3.2	Universal ID	2.16.840.1.113883.3.72.5.40.3
MSH-3.3	Universal ID Type	ISO
MSH-4	Sending Facility
MSH-4.1	Namespace ID	NISTIISFAC
MSH-4.2	Universal ID	2.16.840.1.113883.3.72.5.40.4
MSH-4.3	Universal ID Type	ISO
MSH-5	Receiving Application
MSH-5.1	Namespace ID	NISTEHRAPP
MSH-5.2	Universal ID	2.16.840.1.113883.3.72.5.40.1
MSH-5.3	Universal ID Type	ISO
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NISTEHRFAC
MSH-6.2	Universal ID	2.16.840.1.113883.3.72.5.40.2
MSH-6.3	Universal ID Type	ISO
MSH-7	Date/Time Of Message
MSH-7.1	Time	20181031145233-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	NIST-IZ-QR-3.2_Response_NF_K11_Z33
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z33
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	NISTIISFAC
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code	XX
MSH-22.10	Organization Identifier	100-3322
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	NISTEHRFAC
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code	XX
MSH-23.10	Organization Identifier	100-6482

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	NIST-IZ-QR-3.1_Query_Q11_Z44

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	IZ-3.1-2015
QAK-2	Query Response Status	NF
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number
QPD-3.4	Assigning Authority
QPD-3.5	Identifier Type Code
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Gonzales
QPD-4.2	Given Name	Juana
QPD-4.3	Second and Further Given Names or Initials Thereof	Maria
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Morales
QPD-5.7	Name Type Code	M
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201810011115
QPD-7	Patient Sex	F
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code	06903
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	PH
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551214
QPD-10	Multiple birth indicator
QPD-11	Birth order

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

5.1.6. Query Registry for vaccination history and forecast for Juana Maria Gonzales

Test Step Type: SUT_INITIATOR
Vendor SHALL be able to Generate a Z44 Query correctly and without ommission according to supplied test data

Test Story

Description
The provider uses the EMR to query the Immunization Registry for an Evaluated History and Forecast based on information known to the Immunization Registry.

Comments
This step is a repeat of Step 2: Query Registry for vaccination history and forecast for Juana Maria Gonzales in order to set up the response for the history and forecast that will be imported in the following step.

Pre-condition

Juana Maria Gonzales Initial Data Load is completed.

Juana Maria Gonzales is the active working patient in the EMR.

Post-Condition
The Immunization Registry responds with Evaluated Vaccine History and Forecast for Juana Maria Gonzales.

Test Objectives

Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (QBP/RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5).

Evaluation Criteria
Tester verifies that the message has been created and submitted in the test plan to trigger the error handling response in the next step.

Notes
Query step is the same as Step 2: Query Registry for vaccination history and forecast for Juana Maria Gonzales . No new requirements tested

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20180515001020-0500
MSH-9	Message Type
MSH-9.1	Message Code	QBP
MSH-9.2	Trigger Event	Q11
MSH-9.3	Message Structure	QBP_Q11
MSH-10	Message Control ID	793543
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z44
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

QPD : Query Parameter Definition

Location	Data Element	Data	Categorization
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number	123456
QPD-3.4	Assigning Authority
QPD-3.5	Identifier Type Code	MR
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Gonzales	Value-Test Case Fixed
QPD-4.2	Given Name	Juana	Value-Test Case Fixed
QPD-4.3	Second and Further Given Names or Initials Thereof	Maria	Value-Test Case Fixed
QPD-4.7	Name Type Code	L	Value-Test Case Fixed
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Morales	Value-Test Case Fixed
QPD-5.7	Name Type Code	M	Value-Test Case Fixed
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201810011115	Value-Test Case Fixed
QPD-7	Patient Sex	F	Value-Test Case Fixed
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code	06903
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	CP
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551214
QPD-10	Multiple birth indicator	Y	Value-Test Case Fixed
QPD-11	Birth order	2	Value-Test Case Fixed

RCP : Response Control Parameter

Location	Data Element	Data
RCP-1	Query Priority	I
RCP-2	Quantity Limited Request
RCP-2.1	Quantity	1
RCP-2.2	Units
RCP-2.2.1	Identifier	RD
RCP-2.2.2	Text	Records
RCP-2.2.3	Name of Coding System	HL70126

Test Data Specification

Patient Information

Element	Data
Patient Name	Juana Maria Gonzales
Mother's Maiden Name	Morales
ID Number	123456
Date/Time of Birth	10/01/2018 11:15
Sex	Female
Patient Address	3321 Standish Way Stamford CT 06903
Patient Phone	(203)555-1214
Birth Indicator	Yes
Birth Order	2

5.1.7. View and import response to request for vaccination history for Juana Maria Gonzales

Test Step Type: TA_RESPONDER
The EMR displays the Immunization History results (Z42) returned in response to the Z44 Query and import them into the EMR.

Test Story

Description

The physician accesses the record for Juana Maria Gonzales and:

- Accepts the single vaccine in the registry record into the EHR history

Comments
There is no reconciliation step as there are no historical immunizations in the EMR. All will be imported from the Z42 response.

Pre-condition
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import.

Post-Condition
Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juana Maria Gonzales)

Test Objectives

Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5).

Evaluation Criteria

1. The EMR displays the information returned from the Immunization Registry according to the Juror Document.

2. The user imports the vaccination given and the date administered returned from the immunization registry as follows:

a. Vaccinations Imported:

hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 10/1/2018

Notes

The message returns 'BG2' in the first name of the patient as the first immunization was given at the time of birth before the patient's first name was selected. The EMR should be able to import this record into the patient record despite the apparent name mismatch retaining the original name, Juana Maria Gonzales.

If the EMR is unable to match and import the previous immunization record, they will need to add the following historical immunization manually. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:

Vaccine from Practice HepB
Entered BY	Susan Pike	Y
Ordering Provider	Justin Parker	Y
Entering Organization	Shoreline Hospital	Y
Administration Notes (Vaccine Event information source)	New immunization record (NIP001 00)	Y
Date/Time of Start of Administration	10/01/2017	Y
Vaccine Administered	hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08, NDC 58160-0820-01)	Y
Administered Amount (of Vaccine)	0.5	Y
Administered Units (of Measure)	mL	Y
Administering Provider	Susan Pike	Y
Administered-at Location	15 Atlantic Avenue, Stamford, CT, 06903	Y
Lot Number	6332FK34	Y
Substance Expiration Date	12/14/2018	Y
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA (MVX SKB)	Y
Completion Status	Completed (CP)	Y
Route of Administration	Intramuscular (NCIT C28161, HL70162: IM)	Y
Administration Site	Left Thigh (HL70163 LT)	Y

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	MYIIS
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	MyStateIIS
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	MYEHR
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	Myclinic
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20181130020020-0500
MSH-9	Message Type
MSH-9.1	Message Code	RSP
MSH-9.2	Trigger Event	K11
MSH-9.3	Message Structure	RSP_K11
MSH-10	Message Control ID	7731029
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z42
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	A_Clinic
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code	AN
MSH-22.10	Organization Identifier	A_Clinic1234
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AA
MSA-2	Message Control ID	793543

QAK : Query Acknowledgment

Location	Data Element	Data
QAK-1	Query Tag	37374859
QAK-2	Query Response Status	OK
QAK-3	Message Query Name
QAK-3.1	Identifier	Z44
QAK-3.2	Text	Request Evaluated History and Forecast
QAK-3.3	Name of Coding System	CDCPHINVS

QPD : Query Parameter Definition

Location	Data Element	Data
QPD-1	Message Query Name
QPD-1.1	Identifier	Z44
QPD-1.2	Text	Request Evaluated History and Forecast
QPD-1.3	Name of Coding System	CDCPHINVS
QPD-2	Query Tag	37374859
QPD-3	PatientList
QPD-3.1	ID Number	123456
QPD-3.4	Assigning Authority
QPD-3.5	Identifier Type Code	MR
QPD-4	PatientName
QPD-4.1	Family Name
QPD-4.1.1	Surname	Gonzales
QPD-4.2	Given Name	Juana
QPD-4.3	Second and Further Given Names or Initials Thereof	Maria
QPD-4.7	Name Type Code	L
QPD-5	PatientMotherMaidenName
QPD-5.1	Family Name
QPD-5.1.1	Surname	Morales
QPD-5.7	Name Type Code	M
QPD-6	PatientDateOfBirth
QPD-6.1	Time	201810011115
QPD-7	Patient Sex	F
QPD-8	Patient Address
QPD-8.1	Street Address
QPD-8.1.1	Street or Mailing Address	3321 Standish Way
QPD-8.2	Other Designation
QPD-8.3	City	Stamford
QPD-8.4	State or Province	CT
QPD-8.5	Zip or Postal Code	06903
QPD-8.6	Country
QPD-8.7	Address Type	L
QPD-9	Phone
QPD-9.2	Telecommunication Use Code	PRN
QPD-9.3	Telecommunication Equipment Type	CP
QPD-9.4	Email Address
QPD-9.6	Area/City Code	203
QPD-9.7	Local Number	5551214
QPD-10	Multiple birth indicator	Y
QPD-11	Birth order	2

PID : Patient Identification

Location	Data Element	Data
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Morales
PID-5.2	Given Name	BG2
PID-5.3	Second and Further Given Names or Initials Thereof
PID-5.7	Name Type Code	L
PID-7	Date/Time of Birth
PID-7.1	Time	201810011115
PID-8	Administrative Sex	F
PID-11	Patient Address
PID-11.1	Street Address
PID-11.1.1	Street or Mailing Address	3321 Standish Way
PID-11.2	Other Designation
PID-11.3	City	Stamford
PID-11.4	State or Province	CT
PID-11.5	Zip or Postal Code	06903
PID-11.6	Country	USA
PID-11.7	Address Type	L
PID-30	Patient Death Indicator

ORC[*]

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	SH
ORC-17.2	Text	Stamford Regional Hospital
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

ORC : Common Order

Location	Data Element	Data
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	9999
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-17	Entering Organization
ORC-17.1	Identifier	STIIS
ORC-17.2	Text	StateIIS
ORC-17.3	Name of Coding System	HL70362

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181001
RXA-5	Administered Code
RXA-5.1	Identifier	08
RXA-5.2	Text	Hepatitis B
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	0.5
RXA-7	Administered Units
RXA-7.1	Identifier	mL
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM
RXA-9	Administration Notes
RXA-9.1	Identifier	00
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Pike
RXA-10.3	Given Name	Susan
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB
RXA-17.2	Text	GlaxoSmithKline Biologicals SA
RXA-17.3	Name of Coding System	MVX
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031
RXA-5	Administered Code
RXA-5.1	Identifier	998
RXA-5.2	Text	no vaccine admin
RXA-5.3	Name of Coding System	CVX
RXA-6	Administered Amount	999
RXA-7	Administered Units
RXA-7.1	Identifier
RXA-7.2	Text
RXA-7.3	Name of Coding System
RXA-9	Administration Notes
RXA-9.1	Identifier
RXA-9.2	Text
RXA-9.3	Name of Coding System
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname
RXA-10.3	Given Name
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier
RXA-17.2	Text
RXA-17.3	Name of Coding System
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	NA

RXR : Pharmacy/Treatment Route

Location	Data Element	Data
RXR-1	Route
RXR-1.1	Identifier	C28161
RXR-1.2	Text	IM
RXR-1.3	Name of Coding System	NCIT
RXR-2	Administration Site
RXR-2.1	Identifier	LT
RXR-2.2	Text	Left Thigh
RXR-2.3	Name of Coding System	HL70163

OBX[*]

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	Hep B, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	59782-3
OBX-3.2	Text	number of doses in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	3
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	ID
OBX-3	Observation Identifier
OBX-3.1	Identifier	59781-5
OBX-3.2	Text	Dose validity
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	Y
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	45
OBX-5.2	Text	Hep B, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181031
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20171201
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	2
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181216

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	107
OBX-5.2	Text	DTaP, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	17
OBX-5.2	Text	Hib
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	10
OBX-5.2	Text	IPV
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	152
OBX-5.2	Text	Pneumococcal Conjugate, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	122
OBX-5.2	Text	rotavirus, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20181130
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	88
OBX-5.2	Text	influenza, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20190901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20190901
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	85
OBX-5.2	Text	Hep A, unspecified formulation
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20191001
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20191001
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20201002
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	03
OBX-5.2	Text	MMR
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20191001
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20191001
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200101
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30956-7
OBX-3.2	Text	vaccine type
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	21
OBX-5.2	Text	Varicella
OBX-5.3	Name of Coding System	CVX
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	2
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	59779-9
OBX-3.2	Text	Immunization Schedule used
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	VXC16
OBX-5.2	Text	ACIP
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	3
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30981-5
OBX-3.2	Text	Earliest date to give
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20191001
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	4
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	30980-7
OBX-3.2	Text	Date vaccination due
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20191001
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	DT
OBX-3	Observation Identifier
OBX-3.1	Identifier	59778-1
OBX-3.2	Text	Date dose is overdue
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	20200101
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	6
OBX-2	Value Type	NM
OBX-3	Observation Identifier
OBX-3.1	Identifier	30973-2
OBX-3.2	Text	dose number in series
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value	1
OBX-6	Units
OBX-6.1	Identifier	NA
OBX-6.2	Text
OBX-6.3	Name of Coding System	HL70353
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

Juror Document

Evaluated Immunization History and Immunization Forecast

Test Case ID

Query the Registry for Juana Maria Gonzales.

Inspection Settlement (Pass/Fail)

Pass	Fail

Reason Failed

Juror Comments

DISPLAY VERIFICATION

The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.

Patient Information
Element Name	Data	Tester Comment
Patient Identifier
ID Number	123456
Assigning Authority
Namespace ID	MYEHR
ID Type	MR
Patient Identifier
ID Number	987633
Assigning Authority
Namespace ID	MYIIS
ID Type	SR
Name	BG2 Morales
Date of Birth	10/01/2018
Sex	Female
Address 1
Street	3321 Standish Way
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country	USA
Address Type	L
Mother's Maiden Name	Joanna Elena Morales
When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient.

Evaluated Immunization History Information
Element Name	Data	Tester Comment
Entering Organization	Stamford Regional Hospital
Vaccine Group	Hep B, unspecified formulation
Vaccine Administered	Hepatitis B
Refusal Reason
Date/Time Administration-Start	10/01/2018
Date/Time Administration-End	10/01/2018
Administered Amount	0.5
Administered Units of Measure	mL
Route of Administration	IM
Administration Site	Left Thigh
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Administration Notes
Administering Provider
Name	Susan Pike
ID Number
Administered-at Location
Facility ID	DCS_DC
Street Address	15 Atlantic Avenue
Other Designation
City	Stamford
State	CT
Zip Code	06903
Country
Valid Dose	YES
Validity Reason
Completion Status*	Complete
Dose Number in Series	1
Number of Doses in Series	3
Immunization Series Name
Status in Immunization Series
Immunization Schedule Used	ACIP

* "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered".

Immunization Forecast
Element Name	Data	Tester Comment
Vaccine Group	Hep B, unspecified formulation
Vaccine Due Date	10/31/2018
Earliest Date to Give	10/31/2018
Latest Date to Give
Date When Vaccine Overdue	12/01/2017
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	DTaP, unspecified formulation
Vaccine Due Date	11/30/2018
Earliest Date to Give	11/30/2018
Latest Date to Give
Date When Vaccine Overdue	10/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Hib
Vaccine Due Date	11/30/2018
Earliest Date to Give	11/30/2018
Latest Date to Give
Date When Vaccine Overdue	10/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	IPV
Vaccine Due Date	11/30/2018
Earliest Date to Give	11/30/2018
Latest Date to Give
Date When Vaccine Overdue	10/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Pneumococcal Conjugate, unspecified formulation
Vaccine Due Date	11/30/2018
Earliest Date to Give	11/30/2018
Latest Date to Give
Date When Vaccine Overdue	10/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	rotavirus, unspecified formulation
Vaccine Due Date	11/30/2018
Earliest Date to Give	11/30/2018
Latest Date to Give
Date When Vaccine Overdue	10/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	influenza, unspecified formulation
Vaccine Due Date	09/01/2019
Earliest Date to Give	09/01/2019
Latest Date to Give
Date When Vaccine Overdue	10/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Hep A, unspecified formulation
Vaccine Due Date	10/01/2019
Earliest Date to Give	10/01/2019
Latest Date to Give
Date When Vaccine Overdue	10/02/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	MMR
Vaccine Due Date	10/01/2019
Earliest Date to Give	10/01/2019
Latest Date to Give
Date When Vaccine Overdue	01/01/2020
Status in Immunization Series
Forecast Reason
Element Name	Data	Tester Comment
Vaccine Group	Varicella
Vaccine Due Date	10/01/2019
Earliest Date to Give	10/01/2019
Latest Date to Give
Date When Vaccine Overdue	01/01/2020
Status in Immunization Series
Forecast Reason

5.1.8. View the vaccination forecast for Juana Maria Gonzales

Test Step Type: SUT_MANUAL
The EMR displays the current Immunization Forecast to the user for Juana Maria Gonzales either as returned by the IIS in prior step, or as generated thru any local means.

Test Story

Description

The physician accesses the record for Juana Maria Gonzales and:

- Views the vaccine forecast (either as provided by the Immunization Registry or as determined through EMR defined methods)

Comments
No Comments

Pre-condition
EMR Vaccine History is imported from the Immunization History returned from the Immunization Registry (previous step 'View and import response to request for vaccination history for Juana Maria Gonzales)

Post-Condition
A vaccine forecast based upon the imported vaccine history is available to the user.

Test Objectives

Evaluation Criteria

1. Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history:
2. Verify that the EMR includes in the vaccine forecast:

Hep B Peds NOS due on 10/31/2018
DTaP due on 11/30/2018
Hib due on 11/30/2018

IPV due on 11/30/2018

Pneumococcal conjugate due on 11/30/2018
Rotavirus due on 11/30/2018
HepA due on 10/1/2019
MMR due on 10/1/2019

Varicella due on 10/1/2019

influenza, unspecified formulation due on Sept 1, 2019 or later

Notes

The due date must be in range for the date shown. Vaccine forecast dates may be plus or minus 10 days to accommodate differences in date handling.

Further variation should be documented in the notable exceptions, but minimally each forecast vaccine must be present.

5.2. Juana Maria Gonzales, Enter Orders and Immunizations

Orders and Immunization events, non-administrations, and alerts presented for current visit.

Test Story

Description
This test will consist of ordering vaccines for the test patients, reviewing any alerts caused by specific scenarios, and documenting vaccinations administered to the patients.

Comments
No Comments

Pre-condition
Juana Maria Gonzales is entered as a patient in the EMR with complete Demographic data, Immunization History Data, and Clinical Data according to the steps in the 'Juana Maria Gonzales Initial Data Load'

Post-Condition
Visit orders are entered in Juana Maria Gonzales' record.

Test Objectives

Supporting data for error handling tests.

Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered. The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size.

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
No Note

5.2.1. Record Combo Vaccine administration

Test Step Type: SUT_MANUAL
The EMR is able to document all attributes associated with the new vaccine administration.

Test Story

Description

The nurse administers the the DTaP-hepatitis B and poliovirus vaccine
- Documents all required information for the vaccine

Comments
No Comments

Pre-condition
Order is placed for DTaP-hepatitis B and poliovirus vaccine.

Post-Condition
The DTaP-hepatitis B and poliovirus vaccination is recorded in the EMR.

Test Objectives

Evaluation Criteria

Entered BY	Sandra Molina
Ordering Provider	Frank Smith
Entering Organization	Shoreline Pediatrics
Vaccine Event information source	New immunization record (NIP001 00)
Date/Time of Start of Administration	Current Date
Vaccine Administered	DTaP-hepatitis B and poliovirus vaccine (CVX 110) Pediarix (NDC 58160-0811-52)
Administered Amount (of Vaccine)	0.5
Administered Units (of Measure)	mL
Administration Notes
Administering Provider	Sandra Molina
Administered-at Location	400 Shoreline Drive, Stamford Connecticut 06901
Lot Number	6559FK32
Substance Expiration Date	12/31/2019
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA (MVX SKB)
Completion Status	Completed (CP)
Route of Administration	Intramuscular (NCIT C28161, HL70162: IM)
Administration Site	Left Deltoid (HL70163 LD)
VFC Eligibility	No
Funding Source	Private

Notes
The EMR does not need to specify a 'new immunization', as long as there is a way to indicate that it is a new immunization within the EMR, this is acceptable (e.g. the default interpretation of the data entry is that it is a new immunization and not historical).

5.3. Juana Maria Gonzales Morales Transmit Immunization Report - Error Handling

This Test Case verifies the ability of the EMR to handle errors and warnings in response to the Send the Immunization Report to the Immunization Registry (VXU/Z22) transaction for Juana Maria Gonzales.

Test Story

Description
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report MAY send the immunizations that the EMR imported from the IIS. This transaction will result in an error or warning from the IIS.

Comments
No Comments

Pre-condition
The vaccines for the visit have been administered.

Post-Condition
The IIS has received the vaccine information (Z22 message) and issued a Z23 response with an error or warning.

Test Objectives

Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries.

Verify that the EMR is able to receive and display the error or warning response from the IIS.

Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization.
a. NDC codes, CVX for immunizations

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
No Note

5.3.1. Transmit the Immunization Report for Juana Maria Gonzales Morales - Fatal Error Handling

Test Step Type: SUT_INITIATOR
The EMR sends the Immunization Report to the Immunization Registry (VXU/Z22) for updated vaccination information from the visit. This will result in a fatal error from the IIS to assess the EMR ability to receive and display the error.

Test Story

Description
Following the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The report MAY send the immunizations that the EMR imported from the IIS. This will result in a warning from the IIS to assess the EMR ability to receive and display the error.

Comments
The Report must include all vaccine deferrals recorded in the EMR in any order. The report may include the information imported from the IIS

Pre-condition
The vaccines for the visit have been administered.

Post-Condition
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission.

Test Objectives

Setup to verify that the EMR is able to receive and display the error response from the IIS.

Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization.
a. NDC codes, CVX for immunizations

Evaluation Criteria
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content.

Notes
The protection indicator for Juana Maria is 'Yes'. If this setting restricts the EMR from transmitting to the IIS, then the protection indicator for Juana Maria may be modified to 'No' for the purpose of this transaction.

Message Contents

MSH : Message Header

Location	Data Element	Data	Categorization
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	Test EHR Application
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	X68
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NIST Test Iz Reg
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20180701082240-0500
MSH-9	Message Type
MSH-9.1	Message Code	VXU
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	VXU_V04
MSH-10	Message Control ID	NIST-IZ-001.00
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z22
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	IIPEHRFAC	Presence-Content Indifferent
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code	XX	Presence-Content Indifferent
MSH-22.10	Organization Identifier	100-1	Presence-Content Indifferent
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	IIPIISFAC	Presence-Content Indifferent
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code	XX	Presence-Content Indifferent
MSH-23.10	Organization Identifier	100-2	Presence-Content Indifferent

PID : Patient Identification

Location	Data Element	Data	Categorization
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales	Value-Test Case Fixed
PID-5.2	Given Name	Juana	Value-Test Case Fixed
PID-5.3	Second and Further Given Names or Initials Thereof	Maria	Value-Test Case Fixed
PID-5.7	Name Type Code	L
PID-6	Mother's Maiden Name
PID-6.1	Family Name
PID-6.1.1	Surname	Morales
PID-6.7	Name Type Code	M
PID-7	Date/Time of Birth
PID-7.1	Time	201810011115	Value-Test Case Fixed
PID-8	Administrative Sex	F	Value-Test Case Fixed
PID-10	Race
PID-10.1	Identifier	2106-3	Value-Test Case Fixed
PID-10.2	Text	White	Presence-Content Indifferent
PID-10.3	Name of Coding System	CDCREC	Value-Test Case Fixed
PID-11[1]	Patient Address
PID-11[1].1	Street Address
PID-11[1].1.1	Street or Mailing Address	3321 Standish Way	Value-Test Case Fixed
PID-11[1].2	Other Designation
PID-11[1].3	City	Stamford	Value-Test Case Fixed
PID-11[1].4	State or Province	CT	Value-Test Case Fixed
PID-11[1].5	Zip or Postal Code	06903	Value-Test Case Fixed
PID-11[1].6	Country	USA	Value-Test Case Fixed
PID-11[1].7	Address Type	L	Value-Test Case Fixed
PID-11[2]	Patient Address
PID-11[2].1	Street Address
PID-11[2].1.1	Street or Mailing Address	325 Shorline Drive
PID-11[2].2	Other Designation
PID-11[2].3	City	Stamford
PID-11[2].4	State or Province	CT
PID-11[2].5	Zip or Postal Code	06901
PID-11[2].6	Country
PID-11[2].7	Address Type	BDL
PID-13	Phone Number - Home
PID-13.2	Telecommunication Use Code	PRN	Value-Test Case Fixed
PID-13.3	Telecommunication Equipment Type	CP	Value-Test Case Fixed
PID-13.4	Email Address
PID-13.6	Area/City Code	203	Value-Test Case Fixed
PID-13.7	Local Number	5551214	Value-Test Case Fixed
PID-22	Ethnic Group
PID-22.1	Identifier	2135-2	Value-Test Case Fixed
PID-22.2	Text	Hispanic or Latino	Presence-Content Indifferent
PID-22.3	Name of Coding System	CDCREC	Value-Test Case Fixed
PID-24	Multiple Birth Indicator	Y	Value-Test Case Fixed
PID-25	Birth Order	2
PID-29	Patient Death Date and Time
PID-29.1	Time
PID-30	Patient Death Indicator

PD1 : Patient Additional Demographic

Location	Data Element	Data	Categorization
PD1-11	Publicity Code
PD1-11.1	Identifier	03	Value-Test Case Fixed
PD1-11.2	Text	Reminder/recall - no calls	Presence-Content Indifferent
PD1-11.3	Name of Coding System	HL70215	Value-Test Case Fixed
PD1-12	Protection Indicator	Y	Value-Test Case Fixed
PD1-13	Protection Indicator Effective Date
PD1-16	Immunization Registry Status	A	Value-Test Case Fixed
PD1-17	Immunization Registry Status Effective Date	20181001	Presence-Content Indifferent
PD1-18	Publicity Code Effective Date	20181001	Presence-Content Indifferent

NK1 : Next of Kin / Associated Parties

Location	Data Element	Data	Categorization
NK1-1	Set ID - NK1	1
NK1-2	Name
NK1-2.1	Family Name
NK1-2.1.1	Surname	Gonzales	Value-Test Case Fixed
NK1-2.2	Given Name	Joanna	Value-Test Case Fixed
NK1-2.3	Second and Further Given Names or Initials Thereof	Elena	Value-Test Case Fixed
NK1-2.7	Name Type Code	L	Value-Test Case Fixed
NK1-3	Relationship
NK1-3.1	Identifier	MTH	Value-Test Case Fixed
NK1-3.2	Text	Mother	Presence-Configuration
NK1-3.3	Name of Coding System	HL70063	Value-Test Case Fixed
NK1-4	Address
NK1-4.1	Street Address
NK1-4.1.1	Street or Mailing Address	3321 Standish Way	Indifferent
NK1-4.2	Other Designation
NK1-4.3	City	Stamford	Indifferent
NK1-4.4	State or Province	CT	Indifferent
NK1-4.5	Zip or Postal Code	06903	Indifferent
NK1-4.6	Country
NK1-4.7	Address Type	L	Indifferent
NK1-5	Phone Number
NK1-5.2	Telecommunication Use Code	PRN	Indifferent
NK1-5.3	Telecommunication Equipment Type	PH	Indifferent
NK1-5.4	Email Address
NK1-5.6	Area/City Code	203	Indifferent
NK1-5.7	Local Number	5551214	Indifferent

ORC[*]

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Sirtis	Presence-Content Indifferent
ORC-10.3	Given Name	Lisa	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Carter	Indifferent
ORC-12.3	Given Name	Jane	Indifferent
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L	Indifferent
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SH	Presence-Content Indifferent
ORC-17.2	Text	Shoreline Hospital	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Sirtis	Value-Test Case Fixed
ORC-10.3	Given Name	Lisa	Value-Test Case Fixed
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Carter	Value-Test Case Fixed
ORC-12.3	Given Name	Jane	Value-Test Case Fixed
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SH	Presence-Content Indifferent
ORC-17.2	Text	Shoreline Hospital	Value-Test Case Fixed
ORC-17.3	Name of Coding System	HL70362	Value-Test Case Fixed

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181001	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	08	Value-Test Case Fixed
RXA-5.2	Text	Hepatitis B	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5	Indifferent
RXA-7	Administered Units
RXA-7.1	Identifier	mL	Indifferent
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM	Indifferent
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Presence-Content Indifferent
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Presence-Configuration
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Pike	Indifferent
RXA-10.3	Given Name	Susan	Indifferent
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6332FL432
RXA-16	Substance Expiration Date
RXA-16.1	Time	20181214	Indifferent
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB	Indifferent
RXA-17.2	Text	GlaxoSmithKline Biologicals SA	Indifferent
RXA-17.3	Name of Coding System	MVX	Indifferent
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP	Value-Test Case Fixed
RXA-21	Action Code - RXA	A	Value-Test Case Fixed

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031	Presence-Content Indifferent
RXA-5	Administered Code
RXA-5.1	Identifier	58160-0811-52	Value-Test Case Fixed
RXA-5.2	Text	Pediarix	Presence-Content Indifferent
RXA-5.3	Name of Coding System	NDC	Value-Test Case Fixed
RXA-6	Administered Amount	0.5	Value-Test Case Fixed
RXA-7	Administered Units
RXA-7.1	Identifier	mL	Value-Test Case Fixed
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM	Value-Test Case Fixed
RXA-9	Administration Notes
RXA-9.1	Identifier	00	Value-Test Case Fixed
RXA-9.2	Text	New immunization record	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina	Value-Test Case Fixed
RXA-10.3	Given Name	Sandra	Value-Test Case Fixed
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6559FK32	Value-Test Case Fixed
RXA-16	Substance Expiration Date
RXA-16.1	Time	20191031	Value-Test Case Fixed
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB	Value-Test Case Fixed
RXA-17.2	Text	GlaxoSmithKline Biologicals SA	Presence-Content Indifferent
RXA-17.3	Name of Coding System	MVX	Value-Test Case Fixed
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP	Value-Test Case Fixed
RXA-21	Action Code - RXA	A	Value-Test Case Fixed

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data	Categorization
RXR-1	Route
RXR-1.1	Identifier	C28161	Indifferent
RXR-1.2	Text	Intramuscular	Indifferent
RXR-1.3	Name of Coding System	NCIT	Indifferent
RXR-2	Administration Site
RXR-2.1	Identifier	LT	Indifferent
RXR-2.2	Text	Left Thigh	Indifferent
RXR-2.3	Name of Coding System	HL70163	Indifferent

RXR : Pharmacy/Treatment Route

Location	Data Element	Data	Categorization
RXR-1	Route
RXR-1.1	Identifier	C28161	Value-Test Case Fixed
RXR-1.2	Text	Intramuscular	Presence-Content Indifferent
RXR-1.3	Name of Coding System	NCIT	Value-Test Case Fixed
RXR-2	Administration Site
RXR-2.1	Identifier	LT	Value-Test Case Fixed
RXR-2.2	Text	Left Thigh	Presence-Content Indifferent
RXR-2.3	Name of Coding System	HL70163	Value-Test Case Fixed

OBX[*]

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9	Value-Test Case Fixed
OBX-3.2	Text	Document Type	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300026411121116	Presence-Content Indifferent
OBX-5.2	Text	Multiple Vaccines VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F	Value-Test Case Fixed
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9	Value-Test Case Fixed
OBX-3.2	Text	VIS Publication Date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20180824	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	3
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7	Value-Test Case Fixed
OBX-3.2	Text	VIS Presentation Date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20181031	Value-Test Case Fixed
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	4
OBX-2	Value Type	CE	Value-Test Case Fixed
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7	Value-Test Case Fixed
OBX-3.2	Text	vaccine fund pgm elig cat	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V04	Value-Test Case Fixed
OBX-5.2	Text	VFC eligible	Presence-Content Indifferent
OBX-5.3	Name of Coding System	HL70064	Value-Test Case Fixed
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F	Value-Test Case Fixed
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30963-3
OBX-3.2	Text	Vaccine funding source
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	PHC70
OBX-5.2	Text	Private
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

Test Data Specification

Patient Information

Element	Data
Patient Name	Juana Maria Gonzales
Mother's Maiden Name	Joanna Morales
ID Number	123456 987633
Date/Time of Birth	10/01/2018 11:15
Administrative Sex	Female
Patient Address 1	3321 Standish Way Stamford CT 06903 USA
Patient Address 2	325 Shorline Drive Stamford CT 06901
Local Number	(203)555-1214
Race	White
Ethnic Group	Hispanic or Latino
Multiple Birth Indicator	Yes
Birth Order	2

Immunization Registry Information

Element	Data
Immunization Registry Status	Active
Immunization Registry Status Effective Date	10/01/2018
Publicity Code	Reminder/recall - no calls
Publicity Code Effective Date	10/01/2018
Protection Indicator	Yes
Protection Indicator Effective Date

Guardian or Responsible Party

Element	Data
Name	Joanna Elena Gonzales
Relationship	Mother
Address	3321 Standish Way Stamford CT 06903
Phone Number	(203)555-1214

Vaccine Administration Information[*]

Vaccine Administration Information

Element	Data
Administered Vaccine	Hepatitis B
Date/Time Start of Administration	10/01/2018
Administered Amount	0.5
Administered Units
Administration Notes
Administering Provider	Susan Pike
Substance Lot Number	6332FL432
Substance Expiration Date	12/14/2018
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Shoreline Hospital
Entered By	Lisa Sirtis
Ordered By	Jane Carter

Vaccine Administration Information

Element	Data
Administered Vaccine	Pediarix
Date/Time Start of Administration	10/31/2018
Administered Amount	0.5
Administered Units
Administration Notes	New immunization record
Administering Provider	Sandra Molina
Substance Lot Number	6559FK32
Substance Expiration Date	10/31/2019
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Shoreline Hospital
Entered By	Lisa Sirtis
Ordered By	Jane Carter

Element	Data
Document Type	Multiple Vaccines VIS
VIS Publication Date	08/24/2018
VIS Presentation Date	10/31/2018
vaccine fund pgm elig cat	VFC eligible
Vaccine funding source	Private

5.3.2. Receive ACK Z23 Fatal Error - CVX Code

Test Step Type: TA_RESPONDER
The Immunization Registry returns a fatal error message indicating a table mapping error for the CVX code submitted was found during the course of filing the message.

Test Story

Description

The Immunization Registry returns a fatal error message indicating a table mapping error for the CVX code submitted was found during the course of filing the message.

Comments
No Comments

Pre-condition
A VXU message is generated by the EHR.

Post-Condition
The ACK Z23 is received by the EHR.

Test Objectives

Error Handling Support for a fatal error returned by the IIS, and the ability of the EMR to display a notification of this error to the user.

Evaluation Criteria
The acknowledgement error message is consumed by the system responsible for the content of the administration message. The error returned is visible in the EMR .

Notes
Important note regarding the MSH-10 and MSA-2: The NIST acknowledgment message is predefined and is based on the VXU message. Most systems will automatically create the message control Identifier and may require it for importing, linking, and processing the ACK message. The NIST ACK test message can be modified such that MSA-2 matches MSH-10 of the VXU message generated by the system-under test.

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	NISTIISAPP
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	NISTIISFAC
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	NISTEHRAPP
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NISTEHRFAC
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20180625121047.853-0500
MSH-9	Message Type
MSH-9.1	Message Code	ACK
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	ACK
MSH-10	Message Control ID	NIST-IZ-AD-7.2_Receive_ACK_Z23
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z23
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	NISTIISFAC
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code	XX
MSH-22.10	Organization Identifier	100-3322
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	NISTEHRFAC
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code	XX
MSH-23.10	Organization Identifier	100-6482

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AE
MSA-2	Message Control ID	NIST-IZ-AD-7.1_Send_V04_Z22

ERR : Error

Location	Data Element	Data
ERR-2	Error Location
ERR-2.1	Segment ID	RXA
ERR-2.2	Segment Sequence	1
ERR-2.3	Field Position	5
ERR-2.4	Field Repetition	1
ERR-2.5	Component Number	1
ERR-2.6	Sub-Component Number
ERR-3	HL7 Error Code
ERR-3.1	Identifier	999
ERR-3.2	Text	Application error
ERR-3.3	Name of Coding System	HL70357
ERR-4	Severity	E
ERR-5	Application Error Code
ERR-5.1	Identifier	5
ERR-5.2	Text	Table value not found
ERR-5.3	Name of Coding System	HL70533
ERR-8	User Message	Vaccine code not recognized - message rejected

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

5.3.3. Transmit the Immunization Report for Juana Maria Gonzales - warning handling

Test Step Type: SUT_INITIATOR
The EMR sends the Immunization Report to the Immunization Registry (VXU/Z22) for updated vaccination information from the visit. This will result in a warning from the IIS to assess the EMR ability to receive and display the warning.

Test Story

Description
Following the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. This will result in multiple warnings from the IIS to assess the EMR ability to receive and display the error.

Comments
The Report must include the newly administered vaccine recorded in the EMR. The report may include the information imported from the IIS

Pre-condition
The vaccines for the visit have been administered.

Post-Condition
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission.

Test Objectives

Set up to verify that the EMR is able to receive and display the multiple warning response from the IIS.

Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization.
a. NDC codes, CVX for immunizations

Evaluation Criteria
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content.

Notes
The protection indicator for Juana Maria is 'Yes'. If this setting restricts the EMR from transmitting to the IIS, then the protection indicator for Juana Maria may be modified to 'No' for the purpose of this transaction.

Message Contents

MSH : Message Header

Location	Data Element	Data	Categorization
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	Test EHR Application
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	X68
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NIST Test Iz Reg
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20180701082240-0500
MSH-9	Message Type
MSH-9.1	Message Code	VXU
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	VXU_V04
MSH-10	Message Control ID	NIST-IZ-001.00
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z22
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	IIPEHRFAC	Presence-Content Indifferent
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code	XX	Presence-Content Indifferent
MSH-22.10	Organization Identifier	100-1	Presence-Content Indifferent
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	IIPIISFAC	Presence-Content Indifferent
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code	XX	Presence-Content Indifferent
MSH-23.10	Organization Identifier	100-2	Presence-Content Indifferent

PID : Patient Identification

Location	Data Element	Data	Categorization
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales	Value-Test Case Fixed
PID-5.2	Given Name	Juana	Value-Test Case Fixed
PID-5.3	Second and Further Given Names or Initials Thereof	Maria	Value-Test Case Fixed
PID-5.7	Name Type Code	L
PID-6	Mother's Maiden Name
PID-6.1	Family Name
PID-6.1.1	Surname	Morales
PID-6.7	Name Type Code	M
PID-7	Date/Time of Birth
PID-7.1	Time	201810011115	Value-Test Case Fixed
PID-8	Administrative Sex	F	Value-Test Case Fixed
PID-10	Race
PID-10.1	Identifier	2106-3	Value-Test Case Fixed
PID-10.2	Text	White	Presence-Content Indifferent
PID-10.3	Name of Coding System	CDCREC	Value-Test Case Fixed
PID-11[1]	Patient Address
PID-11[1].1	Street Address
PID-11[1].1.1	Street or Mailing Address	3321 Standish Way	Value-Test Case Fixed
PID-11[1].2	Other Designation
PID-11[1].3	City	Stamford	Value-Test Case Fixed
PID-11[1].4	State or Province	CT	Value-Test Case Fixed
PID-11[1].5	Zip or Postal Code	06903	Value-Test Case Fixed
PID-11[1].6	Country	USA	Value-Test Case Fixed
PID-11[1].7	Address Type	L	Value-Test Case Fixed
PID-11[2]	Patient Address
PID-11[2].1	Street Address
PID-11[2].1.1	Street or Mailing Address	325 Shorline Drive
PID-11[2].2	Other Designation
PID-11[2].3	City	Stamford
PID-11[2].4	State or Province	CT
PID-11[2].5	Zip or Postal Code	06901
PID-11[2].6	Country
PID-11[2].7	Address Type	BDL
PID-13	Phone Number - Home
PID-13.2	Telecommunication Use Code	PRN	Value-Test Case Fixed
PID-13.3	Telecommunication Equipment Type	CP	Value-Test Case Fixed
PID-13.4	Email Address
PID-13.6	Area/City Code	203	Value-Test Case Fixed
PID-13.7	Local Number	5551214	Value-Test Case Fixed
PID-22	Ethnic Group
PID-22.1	Identifier	2135-2	Value-Test Case Fixed
PID-22.2	Text	Hispanic or Latino	Presence-Content Indifferent
PID-22.3	Name of Coding System	CDCREC	Value-Test Case Fixed
PID-24	Multiple Birth Indicator	Y	Value-Test Case Fixed
PID-25	Birth Order	2
PID-29	Patient Death Date and Time
PID-29.1	Time
PID-30	Patient Death Indicator

PD1 : Patient Additional Demographic

Location	Data Element	Data	Categorization
PD1-11	Publicity Code
PD1-11.1	Identifier	03	Value-Test Case Fixed
PD1-11.2	Text	Reminder/recall - no calls	Presence-Content Indifferent
PD1-11.3	Name of Coding System	HL70215	Value-Test Case Fixed
PD1-12	Protection Indicator	Y	Value-Test Case Fixed
PD1-13	Protection Indicator Effective Date
PD1-16	Immunization Registry Status	A	Value-Test Case Fixed
PD1-17	Immunization Registry Status Effective Date	20181001	Presence-Content Indifferent
PD1-18	Publicity Code Effective Date	20181001	Presence-Content Indifferent

NK1 : Next of Kin / Associated Parties

Location	Data Element	Data	Categorization
NK1-1	Set ID - NK1	1
NK1-2	Name
NK1-2.1	Family Name
NK1-2.1.1	Surname	Gonzales	Value-Test Case Fixed
NK1-2.2	Given Name	Joanna	Value-Test Case Fixed
NK1-2.3	Second and Further Given Names or Initials Thereof	Elena	Value-Test Case Fixed
NK1-2.7	Name Type Code	L	Value-Test Case Fixed
NK1-3	Relationship
NK1-3.1	Identifier	MTH	Value-Test Case Fixed
NK1-3.2	Text	Mother	Presence-Configuration
NK1-3.3	Name of Coding System	HL70063	Value-Test Case Fixed
NK1-4	Address
NK1-4.1	Street Address
NK1-4.1.1	Street or Mailing Address	3321 Standish Way	Indifferent
NK1-4.2	Other Designation
NK1-4.3	City	Stamford	Indifferent
NK1-4.4	State or Province	CT	Indifferent
NK1-4.5	Zip or Postal Code	06903	Indifferent
NK1-4.6	Country
NK1-4.7	Address Type	L	Indifferent
NK1-5	Phone Number
NK1-5.2	Telecommunication Use Code	PRN	Indifferent
NK1-5.3	Telecommunication Equipment Type	PH	Indifferent
NK1-5.4	Email Address
NK1-5.6	Area/City Code	203	Indifferent
NK1-5.7	Local Number	5551214	Indifferent

ORC[*]

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Sirtis	Presence-Content Indifferent
ORC-10.3	Given Name	Lisa	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Carter	Indifferent
ORC-12.3	Given Name	Jane	Indifferent
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L	Indifferent
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SH	Presence-Content Indifferent
ORC-17.2	Text	Shoreline Hospital	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Sirtis	Value-Test Case Fixed
ORC-10.3	Given Name	Lisa	Value-Test Case Fixed
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Carter	Value-Test Case Fixed
ORC-12.3	Given Name	Jane	Value-Test Case Fixed
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SH	Presence-Content Indifferent
ORC-17.2	Text	Shoreline Hospital	Value-Test Case Fixed
ORC-17.3	Name of Coding System	HL70362	Value-Test Case Fixed

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181001	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	08	Value-Test Case Fixed
RXA-5.2	Text	Hepatitis B	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5	Indifferent
RXA-7	Administered Units
RXA-7.1	Identifier	mL	Indifferent
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM	Indifferent
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Presence-Content Indifferent
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Presence-Configuration
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Pike	Indifferent
RXA-10.3	Given Name	Susan	Indifferent
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6332FL432
RXA-16	Substance Expiration Date
RXA-16.1	Time	20181214	Indifferent
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB	Indifferent
RXA-17.2	Text	GlaxoSmithKline Biologicals SA	Indifferent
RXA-17.3	Name of Coding System	MVX	Indifferent
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP	Value-Test Case Fixed
RXA-21	Action Code - RXA	A	Value-Test Case Fixed

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031	Presence-Content Indifferent
RXA-5	Administered Code
RXA-5.1	Identifier	58160-0811-52	Value-Test Case Fixed
RXA-5.2	Text	Pediarix	Presence-Content Indifferent
RXA-5.3	Name of Coding System	NDC	Value-Test Case Fixed
RXA-6	Administered Amount	0.5	Value-Test Case Fixed
RXA-7	Administered Units
RXA-7.1	Identifier	mL	Value-Test Case Fixed
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM	Value-Test Case Fixed
RXA-9	Administration Notes
RXA-9.1	Identifier	00	Value-Test Case Fixed
RXA-9.2	Text	New immunization record	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina	Value-Test Case Fixed
RXA-10.3	Given Name	Sandra	Value-Test Case Fixed
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6559FK32	Value-Test Case Fixed
RXA-16	Substance Expiration Date
RXA-16.1	Time	20191031	Value-Test Case Fixed
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB	Value-Test Case Fixed
RXA-17.2	Text	GlaxoSmithKline Biologicals SA	Presence-Content Indifferent
RXA-17.3	Name of Coding System	MVX	Value-Test Case Fixed
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP	Value-Test Case Fixed
RXA-21	Action Code - RXA	A	Value-Test Case Fixed

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data	Categorization
RXR-1	Route
RXR-1.1	Identifier	C28161	Indifferent
RXR-1.2	Text	Intramuscular	Indifferent
RXR-1.3	Name of Coding System	NCIT	Indifferent
RXR-2	Administration Site
RXR-2.1	Identifier	LT	Indifferent
RXR-2.2	Text	Left Thigh	Indifferent
RXR-2.3	Name of Coding System	HL70163	Indifferent

RXR : Pharmacy/Treatment Route

Location	Data Element	Data	Categorization
RXR-1	Route
RXR-1.1	Identifier	C28161	Value-Test Case Fixed
RXR-1.2	Text	Intramuscular	Presence-Content Indifferent
RXR-1.3	Name of Coding System	NCIT	Value-Test Case Fixed
RXR-2	Administration Site
RXR-2.1	Identifier	LT	Value-Test Case Fixed
RXR-2.2	Text	Left Thigh	Presence-Content Indifferent
RXR-2.3	Name of Coding System	HL70163	Value-Test Case Fixed

OBX[*]

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9	Value-Test Case Fixed
OBX-3.2	Text	Document Type	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300026411121116	Presence-Content Indifferent
OBX-5.2	Text	Multiple Vaccines VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F	Value-Test Case Fixed
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9	Value-Test Case Fixed
OBX-3.2	Text	VIS Publication Date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20180824	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	3
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7	Value-Test Case Fixed
OBX-3.2	Text	VIS Presentation Date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20181031	Value-Test Case Fixed
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	4
OBX-2	Value Type	CE	Value-Test Case Fixed
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7	Value-Test Case Fixed
OBX-3.2	Text	vaccine fund pgm elig cat	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V04	Value-Test Case Fixed
OBX-5.2	Text	VFC eligible	Presence-Content Indifferent
OBX-5.3	Name of Coding System	HL70064	Value-Test Case Fixed
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F	Value-Test Case Fixed
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30963-3
OBX-3.2	Text	Vaccine funding source
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	PHC70
OBX-5.2	Text	Private
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

Test Data Specification

Patient Information

Element	Data
Patient Name	Juana Maria Gonzales
Mother's Maiden Name	Joanna Morales
ID Number	123456 987633
Date/Time of Birth	10/01/2018 11:15
Administrative Sex	Female
Patient Address 1	3321 Standish Way Stamford CT 06903 USA
Patient Address 2	325 Shorline Drive Stamford CT 06901
Local Number	(203)555-1214
Race	White
Ethnic Group	Hispanic or Latino
Multiple Birth Indicator	Yes
Birth Order	2

Immunization Registry Information

Element	Data
Immunization Registry Status	Active
Immunization Registry Status Effective Date	10/01/2018
Publicity Code	Reminder/recall - no calls
Publicity Code Effective Date	10/01/2018
Protection Indicator	Yes
Protection Indicator Effective Date

Guardian or Responsible Party

Element	Data
Name	Joanna Elena Gonzales
Relationship	Mother
Address	3321 Standish Way Stamford CT 06903
Phone Number	(203)555-1214

Vaccine Administration Information[*]

Vaccine Administration Information

Element	Data
Administered Vaccine	Hepatitis B
Date/Time Start of Administration	10/01/2018
Administered Amount	0.5
Administered Units
Administration Notes
Administering Provider	Susan Pike
Substance Lot Number	6332FL432
Substance Expiration Date	12/14/2018
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Shoreline Hospital
Entered By	Lisa Sirtis
Ordered By	Jane Carter

Vaccine Administration Information

Element	Data
Administered Vaccine	Pediarix
Date/Time Start of Administration	10/31/2018
Administered Amount	0.5
Administered Units
Administration Notes	New immunization record
Administering Provider	Sandra Molina
Substance Lot Number	6559FK32
Substance Expiration Date	10/31/2019
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Shoreline Hospital
Entered By	Lisa Sirtis
Ordered By	Jane Carter

Element	Data
Document Type	Multiple Vaccines VIS
VIS Publication Date	08/24/2018
VIS Presentation Date	10/31/2018
vaccine fund pgm elig cat	VFC eligible
Vaccine funding source	Private

5.3.4. Receive ACK Z23 Warning - Invalid Value

Test Step Type: TA_RESPONDER
The Immunization Registry returns a warning message indicating an invalid administration site code submitted was found during the course of filing the message.

Test Story

Description

The Immunization Registry returns a warning message indicating an unrecognized administration site code submitted was found during the course of filing the message.

Comments
No Comments

Pre-condition
A VXU message is generated by the EHR.

Post-Condition
The ACK Z23 is received by the EHR.

Test Objectives

Error Handling Support for a warning returned by the IIS, and the ability of the EMR to display a notification of this warning to the user.

Evaluation Criteria
The acknowledgement warning message is consumed by the system responsible for the content of the administration message. The warning returned is visible in the EMR .

Notes
Important note regarding the MSH-10 and MSA-2: The NIST acknowledgment message is predefined and is based on the VXU message. Most systems will automatically create the message control Identifier and may require it for importing, linking, and processing the ACK message. The NIST ACK test message can be modified such that MSA-2 matches MSH-10 of the VXU message generated by the system-under test.

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	NISTIISAPP
MSH-3.2	Universal ID	2.16.840.1.113883.3.72.5.40.3
MSH-3.3	Universal ID Type	ISO
MSH-4	Sending Facility
MSH-4.1	Namespace ID	NISTIISFAC
MSH-4.2	Universal ID	2.16.840.1.113883.3.72.5.40.4
MSH-4.3	Universal ID Type	ISO
MSH-5	Receiving Application
MSH-5.1	Namespace ID	NISTEHRAPP
MSH-5.2	Universal ID	2.16.840.1.113883.3.72.5.40.1
MSH-5.3	Universal ID Type	ISO
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NISTEHRFAC
MSH-6.2	Universal ID	2.16.840.1.113883.3.72.5.40.2
MSH-6.3	Universal ID Type	ISO
MSH-7	Date/Time Of Message
MSH-7.1	Time	20150625103328.758-0500
MSH-9	Message Type
MSH-9.1	Message Code	ACK
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	ACK
MSH-10	Message Control ID	NIST-IZ-AD-8.2_Receive_ACK_Z23
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z23
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	NISTIISFAC
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code	XX
MSH-22.10	Organization Identifier	100-3322
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	NISTEHRFAC
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code	XX
MSH-23.10	Organization Identifier	100-6482

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AE
MSA-2	Message Control ID	NIST-IZ-AD-8.1_Send_V04_Z22

ERR : Error

Location	Data Element	Data
ERR-2	Error Location
ERR-2.1	Segment ID	RXR
ERR-2.2	Segment Sequence	2
ERR-2.3	Field Position	1
ERR-2.4	Field Repetition	1
ERR-2.5	Component Number	1
ERR-2.6	Sub-Component Number
ERR-3	HL7 Error Code
ERR-3.1	Identifier	999
ERR-3.2	Text	Application error
ERR-3.3	Name of Coding System	HL70357
ERR-4	Severity	W
ERR-5	Application Error Code
ERR-5.1	Identifier	5
ERR-5.2	Text	Table value not found
ERR-5.3	Name of Coding System	HL70533
ERR-8	User Message	Administration Site not recognized - site data will not be saved

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

5.3.5. Transmit the Immunization Report for Juana Maria Gonzales - Multiple warning handling

Test Step Type: SUT_INITIATOR
The EMR sends the Immunization Report to the Immunization Registry (VXU/Z22) for updated vaccination information from the visit. This will result in multiple warnings from the IIS to assess the EMR ability to receive and display the warnings.

Test Story

Description
Following the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. This will result in multiple warnings from the IIS to assess the EMR ability to receive and display the warnings.

Comments
The Report must include the newly administered vaccine recorded in the EMR. The report may include the information imported from the IIS

Pre-condition
The vaccines for the visit have been administered.

Post-Condition
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission.

Test Objectives

Set up to verify that the EMR is able to receive and display the multiple warning response from the IIS.

Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization.
a. NDC codes, CVX for immunizations

Evaluation Criteria
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content.

Notes
The protection indicator for Juana Maria is 'Yes'. If this setting restricts the EMR from transmitting to the IIS, then the protection indicator for Juana Maria may be modified to 'No' for the purpose of this transaction.

Message Contents

MSH : Message Header

Location	Data Element	Data	Categorization
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	Test EHR Application
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	X68
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NIST Test Iz Reg
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20180701082240-0500
MSH-9	Message Type
MSH-9.1	Message Code	VXU
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	VXU_V04
MSH-10	Message Control ID	NIST-IZ-001.00
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	ER
MSH-16	Application Acknowledgment Type	AL
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z22
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	IIPEHRFAC	Presence-Content Indifferent
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code	XX	Presence-Content Indifferent
MSH-22.10	Organization Identifier	100-1	Presence-Content Indifferent
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	IIPIISFAC	Presence-Content Indifferent
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code	XX	Presence-Content Indifferent
MSH-23.10	Organization Identifier	100-2	Presence-Content Indifferent

PID : Patient Identification

Location	Data Element	Data	Categorization
PID-1	Set ID - PID	1
PID-3[1]	Patient Identifier List
PID-3[1].1	ID Number	123456
PID-3[1].4	Assigning Authority
PID-3[1].5	Identifier Type Code	MR
PID-3[2]	Patient Identifier List
PID-3[2].1	ID Number	987633
PID-3[2].4	Assigning Authority
PID-3[2].5	Identifier Type Code	SR
PID-5	Patient Name
PID-5.1	Family Name
PID-5.1.1	Surname	Gonzales	Value-Test Case Fixed
PID-5.2	Given Name	Juana	Value-Test Case Fixed
PID-5.3	Second and Further Given Names or Initials Thereof	Maria	Value-Test Case Fixed
PID-5.7	Name Type Code	L
PID-6	Mother's Maiden Name
PID-6.1	Family Name
PID-6.1.1	Surname	Morales
PID-6.7	Name Type Code	M
PID-7	Date/Time of Birth
PID-7.1	Time	201810011115	Value-Test Case Fixed
PID-8	Administrative Sex	F	Value-Test Case Fixed
PID-10	Race
PID-10.1	Identifier	2106-3	Value-Test Case Fixed
PID-10.2	Text	White	Presence-Content Indifferent
PID-10.3	Name of Coding System	CDCREC	Value-Test Case Fixed
PID-11[1]	Patient Address
PID-11[1].1	Street Address
PID-11[1].1.1	Street or Mailing Address	3321 Standish Way	Value-Test Case Fixed
PID-11[1].2	Other Designation
PID-11[1].3	City	Stamford	Value-Test Case Fixed
PID-11[1].4	State or Province	CT	Value-Test Case Fixed
PID-11[1].5	Zip or Postal Code	06903	Value-Test Case Fixed
PID-11[1].6	Country	USA	Value-Test Case Fixed
PID-11[1].7	Address Type	L	Value-Test Case Fixed
PID-11[2]	Patient Address
PID-11[2].1	Street Address
PID-11[2].1.1	Street or Mailing Address	325 Shorline Drive
PID-11[2].2	Other Designation
PID-11[2].3	City	Stamford
PID-11[2].4	State or Province	CT
PID-11[2].5	Zip or Postal Code	06901
PID-11[2].6	Country
PID-11[2].7	Address Type	BDL
PID-13	Phone Number - Home
PID-13.2	Telecommunication Use Code	PRN	Value-Test Case Fixed
PID-13.3	Telecommunication Equipment Type	CP	Value-Test Case Fixed
PID-13.4	Email Address
PID-13.6	Area/City Code	203	Value-Test Case Fixed
PID-13.7	Local Number	5551214	Value-Test Case Fixed
PID-22	Ethnic Group
PID-22.1	Identifier	2135-2	Value-Test Case Fixed
PID-22.2	Text	Hispanic or Latino	Presence-Content Indifferent
PID-22.3	Name of Coding System	CDCREC	Value-Test Case Fixed
PID-24	Multiple Birth Indicator	Y	Value-Test Case Fixed
PID-25	Birth Order	2
PID-29	Patient Death Date and Time
PID-29.1	Time
PID-30	Patient Death Indicator

PD1 : Patient Additional Demographic

Location	Data Element	Data	Categorization
PD1-11	Publicity Code
PD1-11.1	Identifier	03	Value-Test Case Fixed
PD1-11.2	Text	Reminder/recall - no calls	Presence-Content Indifferent
PD1-11.3	Name of Coding System	HL70215	Value-Test Case Fixed
PD1-12	Protection Indicator	Y	Value-Test Case Fixed
PD1-13	Protection Indicator Effective Date
PD1-16	Immunization Registry Status	A	Value-Test Case Fixed
PD1-17	Immunization Registry Status Effective Date	20181001	Presence-Content Indifferent
PD1-18	Publicity Code Effective Date	20181001	Presence-Content Indifferent

NK1 : Next of Kin / Associated Parties

Location	Data Element	Data	Categorization
NK1-1	Set ID - NK1	1
NK1-2	Name
NK1-2.1	Family Name
NK1-2.1.1	Surname	Gonzales	Value-Test Case Fixed
NK1-2.2	Given Name	Joanna	Value-Test Case Fixed
NK1-2.3	Second and Further Given Names or Initials Thereof	Elena	Value-Test Case Fixed
NK1-2.7	Name Type Code	L	Value-Test Case Fixed
NK1-3	Relationship
NK1-3.1	Identifier	MTH	Value-Test Case Fixed
NK1-3.2	Text	Mother	Presence-Configuration
NK1-3.3	Name of Coding System	HL70063	Value-Test Case Fixed
NK1-4	Address
NK1-4.1	Street Address
NK1-4.1.1	Street or Mailing Address	3321 Standish Way	Indifferent
NK1-4.2	Other Designation
NK1-4.3	City	Stamford	Indifferent
NK1-4.4	State or Province	CT	Indifferent
NK1-4.5	Zip or Postal Code	06903	Indifferent
NK1-4.6	Country
NK1-4.7	Address Type	L	Indifferent
NK1-5	Phone Number
NK1-5.2	Telecommunication Use Code	PRN	Indifferent
NK1-5.3	Telecommunication Equipment Type	PH	Indifferent
NK1-5.4	Email Address
NK1-5.6	Area/City Code	203	Indifferent
NK1-5.7	Local Number	5551214	Indifferent

ORC[*]

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Sirtis	Presence-Content Indifferent
ORC-10.3	Given Name	Lisa	Presence-Content Indifferent
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Carter	Indifferent
ORC-12.3	Given Name	Jane	Indifferent
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L	Indifferent
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SH	Presence-Content Indifferent
ORC-17.2	Text	Shoreline Hospital	Presence-Content Indifferent
ORC-17.3	Name of Coding System	HL70362	Presence-Content Indifferent

ORC : Common Order

Location	Data Element	Data	Categorization
ORC-1	Order Control	RE
ORC-2	Placer Order Number
ORC-2.1	Entity Identifier
ORC-2.2	Namespace ID
ORC-2.3	Universal ID
ORC-2.4	Universal ID Type
ORC-3	Filler Order Number
ORC-3.1	Entity Identifier	197027
ORC-3.2	Namespace ID	DCS
ORC-3.3	Universal ID
ORC-3.4	Universal ID Type
ORC-10	Entered By
ORC-10.1	ID Number
ORC-10.2	Family Name
ORC-10.2.1	Surname	Sirtis	Value-Test Case Fixed
ORC-10.3	Given Name	Lisa	Value-Test Case Fixed
ORC-10.4	Second and Further Given Names or Initials Thereof
ORC-10.9	Assigning Authority
ORC-10.10	Name Type Code
ORC-10.13	Identifier Type Code
ORC-12	Ordering Provider
ORC-12.1	ID Number
ORC-12.2	Family Name
ORC-12.2.1	Surname	Carter	Value-Test Case Fixed
ORC-12.3	Given Name	Jane	Value-Test Case Fixed
ORC-12.4	Second and Further Given Names or Initials Thereof
ORC-12.9	Assigning Authority
ORC-12.10	Name Type Code	L
ORC-12.13	Identifier Type Code
ORC-17	Entering Organization
ORC-17.1	Identifier	SH	Presence-Content Indifferent
ORC-17.2	Text	Shoreline Hospital	Value-Test Case Fixed
ORC-17.3	Name of Coding System	HL70362	Value-Test Case Fixed

RXA[*]

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181001	Value-Test Case Fixed
RXA-5	Administered Code
RXA-5.1	Identifier	08	Value-Test Case Fixed
RXA-5.2	Text	Hepatitis B	Presence-Content Indifferent
RXA-5.3	Name of Coding System	CVX	Value-Test Case Fixed
RXA-6	Administered Amount	0.5	Indifferent
RXA-7	Administered Units
RXA-7.1	Identifier	mL	Indifferent
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM	Indifferent
RXA-9	Administration Notes
RXA-9.1	Identifier	08	Presence-Content Indifferent
RXA-9.2	Text
RXA-9.3	Name of Coding System	NIP001	Presence-Configuration
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Pike	Indifferent
RXA-10.3	Given Name	Susan	Indifferent
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6332FL432
RXA-16	Substance Expiration Date
RXA-16.1	Time	20181214	Indifferent
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB	Indifferent
RXA-17.2	Text	GlaxoSmithKline Biologicals SA	Indifferent
RXA-17.3	Name of Coding System	MVX	Indifferent
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP	Value-Test Case Fixed
RXA-21	Action Code - RXA	A	Value-Test Case Fixed

RXA : Pharmacy/Treatment Administration

Location	Data Element	Data	Categorization
RXA-1	Give Sub-ID Counter	0
RXA-2	Administration Sub-ID Counter	1
RXA-3	Date/Time Start of Administration
RXA-3.1	Time	20181031	Presence-Content Indifferent
RXA-5	Administered Code
RXA-5.1	Identifier	58160-0811-52	Value-Test Case Fixed
RXA-5.2	Text	Pediarix	Presence-Content Indifferent
RXA-5.3	Name of Coding System	NDC	Value-Test Case Fixed
RXA-6	Administered Amount	0.5	Value-Test Case Fixed
RXA-7	Administered Units
RXA-7.1	Identifier	mL	Value-Test Case Fixed
RXA-7.2	Text
RXA-7.3	Name of Coding System	UCUM	Value-Test Case Fixed
RXA-9	Administration Notes
RXA-9.1	Identifier	00	Value-Test Case Fixed
RXA-9.2	Text	New immunization record	Presence-Content Indifferent
RXA-9.3	Name of Coding System	NIP001	Value-Test Case Fixed
RXA-10	Administering Provider
RXA-10.1	ID Number
RXA-10.2	Family Name
RXA-10.2.1	Surname	Molina	Value-Test Case Fixed
RXA-10.3	Given Name	Sandra	Value-Test Case Fixed
RXA-10.4	Second and Further Given Names or Initials Thereof
RXA-10.9	Assigning Authority
RXA-10.10	Name Type Code
RXA-10.13	Identifier Type Code
RXA-11	Administered-at Location
RXA-11.4	Facility
RXA-15	Substance Lot Number	6559FK32	Value-Test Case Fixed
RXA-16	Substance Expiration Date
RXA-16.1	Time	20191031	Value-Test Case Fixed
RXA-17	Substance Manufacturer Name
RXA-17.1	Identifier	SKB	Value-Test Case Fixed
RXA-17.2	Text	GlaxoSmithKline Biologicals SA	Presence-Content Indifferent
RXA-17.3	Name of Coding System	MVX	Value-Test Case Fixed
RXA-18	Substance/Treatment Refusal Reason
RXA-18.1	Identifier
RXA-18.2	Text
RXA-18.3	Name of Coding System
RXA-20	Completion Status	CP	Value-Test Case Fixed
RXA-21	Action Code - RXA	A	Value-Test Case Fixed

RXR[*]

RXR : Pharmacy/Treatment Route

Location	Data Element	Data	Categorization
RXR-1	Route
RXR-1.1	Identifier	C28161	Indifferent
RXR-1.2	Text	Intramuscular	Indifferent
RXR-1.3	Name of Coding System	NCIT	Indifferent
RXR-2	Administration Site
RXR-2.1	Identifier	LT	Indifferent
RXR-2.2	Text	Left Thigh	Indifferent
RXR-2.3	Name of Coding System	HL70163	Indifferent

RXR : Pharmacy/Treatment Route

Location	Data Element	Data	Categorization
RXR-1	Route
RXR-1.1	Identifier	C28161	Value-Test Case Fixed
RXR-1.2	Text	Intramuscular	Presence-Content Indifferent
RXR-1.3	Name of Coding System	NCIT	Value-Test Case Fixed
RXR-2	Administration Site
RXR-2.1	Identifier	LT	Value-Test Case Fixed
RXR-2.2	Text	Left Thigh	Presence-Content Indifferent
RXR-2.3	Name of Coding System	HL70163	Value-Test Case Fixed

OBX[*]

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	1
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	69764-9	Value-Test Case Fixed
OBX-3.2	Text	Document Type	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	253088698300026411121116	Presence-Content Indifferent
OBX-5.2	Text	Multiple Vaccines VIS
OBX-5.3	Name of Coding System	cdcgs1vis
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F	Value-Test Case Fixed
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	2
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29768-9	Value-Test Case Fixed
OBX-3.2	Text	VIS Publication Date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20180824	Presence-Content Indifferent
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	3
OBX-2	Value Type	TS
OBX-3	Observation Identifier
OBX-3.1	Identifier	29769-7	Value-Test Case Fixed
OBX-3.2	Text	VIS Presentation Date	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Time	20181031	Value-Test Case Fixed
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data	Categorization
OBX-1	Set ID - OBX	4
OBX-2	Value Type	CE	Value-Test Case Fixed
OBX-3	Observation Identifier
OBX-3.1	Identifier	64994-7	Value-Test Case Fixed
OBX-3.2	Text	vaccine fund pgm elig cat	Presence-Content Indifferent
OBX-3.3	Name of Coding System	LN	Value-Test Case Fixed
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	V04	Value-Test Case Fixed
OBX-5.2	Text	VFC eligible	Presence-Content Indifferent
OBX-5.3	Name of Coding System	HL70064	Value-Test Case Fixed
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F	Value-Test Case Fixed
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031	Presence-Content Indifferent
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

OBX : Observation/Result

Location	Data Element	Data
OBX-1	Set ID - OBX	5
OBX-2	Value Type	CE
OBX-3	Observation Identifier
OBX-3.1	Identifier	30963-3
OBX-3.2	Text	Vaccine funding source
OBX-3.3	Name of Coding System	LN
OBX-4	Observation Sub-ID	1
OBX-5	Observation Value
OBX-5.1	Identifier	PHC70
OBX-5.2	Text	Private
OBX-5.3	Name of Coding System	CDCPHINVS
OBX-6	Units
OBX-6.1	Identifier
OBX-6.2	Text
OBX-6.3	Name of Coding System
OBX-11	Observation Result Status	F
OBX-14	Date/Time of the Observation
OBX-14.1	Time	20181031
OBX-17	Observation Method
OBX-17.1	Identifier
OBX-17.2	Text
OBX-17.3	Name of Coding System

Test Data Specification

Patient Information

Element	Data
Patient Name	Juana Maria Gonzales
Mother's Maiden Name	Joanna Morales
ID Number	123456 987633
Date/Time of Birth	10/01/2018 11:15
Administrative Sex	Female
Patient Address 1	3321 Standish Way Stamford CT 06903 USA
Patient Address 2	325 Shorline Drive Stamford CT 06901
Local Number	(203)555-1214
Race	White
Ethnic Group	Hispanic or Latino
Multiple Birth Indicator	Yes
Birth Order	2

Immunization Registry Information

Element	Data
Immunization Registry Status	Active
Immunization Registry Status Effective Date	10/01/2018
Publicity Code	Reminder/recall - no calls
Publicity Code Effective Date	10/01/2018
Protection Indicator	Yes
Protection Indicator Effective Date

Guardian or Responsible Party

Element	Data
Name	Joanna Elena Gonzales
Relationship	Mother
Address	3321 Standish Way Stamford CT 06903
Phone Number	(203)555-1214

Vaccine Administration Information[*]

Vaccine Administration Information

Element	Data
Administered Vaccine	Hepatitis B
Date/Time Start of Administration	10/01/2018
Administered Amount	0.5
Administered Units
Administration Notes
Administering Provider	Susan Pike
Substance Lot Number	6332FL432
Substance Expiration Date	12/14/2018
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Shoreline Hospital
Entered By	Lisa Sirtis
Ordered By	Jane Carter

Vaccine Administration Information

Element	Data
Administered Vaccine	Pediarix
Date/Time Start of Administration	10/31/2018
Administered Amount	0.5
Administered Units
Administration Notes	New immunization record
Administering Provider	Sandra Molina
Substance Lot Number	6559FK32
Substance Expiration Date	10/31/2019
Substance Manufacturer Name	GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status	Complete
Action Code	Add
Route	Intramuscular
Administration Site	Left Thigh
Entering Organization	Shoreline Hospital
Entered By	Lisa Sirtis
Ordered By	Jane Carter

Element	Data
Document Type	Multiple Vaccines VIS
VIS Publication Date	08/24/2018
VIS Presentation Date	10/31/2018
vaccine fund pgm elig cat	VFC eligible
Vaccine funding source	Private

5.3.6. Receive ACK Z23 Multiple Warnings

Test Step Type: TA_RESPONDER
The Immunization Registry returns a message with multiple warnings for invalid administration site codes submitted found during the course of filing the message.

Test Story

Description

The Immunization Registry returns a message with multiple warnings indicating unrecognized administration site codes submitted were found during the course of filing the message.

Comments
No Comments

Pre-condition
A VXU message is generated by the EHR.

Post-Condition
The ACK Z23 is received by the EHR.

Test Objectives

Error Handling Support for multiple warnings returned by the IIS, and the ability of the EMR to display a notification of these warnings to the user.

Evaluation Criteria
The acknowledgement warning message is consumed by the system responsible for the content of the administration message. The multiple warnings returned is visible in the EMR .

Notes
Important note regarding the MSH-10 and MSA-2: The NIST acknowledgment message is predefined and is based on the VXU message. Most systems will automatically create the message control Identifier and may require it for importing, linking, and processing the ACK message. The NIST ACK test message can be modified such that MSA-2 matches MSH-10 of the VXU message generated by the system-under test.

Message Contents

MSH : Message Header

Location	Data Element	Data
MSH-1	Field Separator	\|
MSH-2	Encoding Characters	^~\&
MSH-3	Sending Application
MSH-3.1	Namespace ID	NISTIISAPP
MSH-3.2	Universal ID
MSH-3.3	Universal ID Type
MSH-4	Sending Facility
MSH-4.1	Namespace ID	NISTIISFAC
MSH-4.2	Universal ID
MSH-4.3	Universal ID Type
MSH-5	Receiving Application
MSH-5.1	Namespace ID	NISTEHRAPP
MSH-5.2	Universal ID
MSH-5.3	Universal ID Type
MSH-6	Receiving Facility
MSH-6.1	Namespace ID	NISTEHRFAC
MSH-6.2	Universal ID
MSH-6.3	Universal ID Type
MSH-7	Date/Time Of Message
MSH-7.1	Time	20180625115038.044-0500
MSH-9	Message Type
MSH-9.1	Message Code	ACK
MSH-9.2	Trigger Event	V04
MSH-9.3	Message Structure	ACK
MSH-10	Message Control ID	NIST-IZ-AD-9.2_Receive_ACK_Z23
MSH-11	Processing ID
MSH-11.1	Processing ID	P
MSH-12	Version ID
MSH-12.1	Version ID	2.5.1
MSH-15	Accept Acknowledgment Type	NE
MSH-16	Application Acknowledgment Type	NE
MSH-21	Message Profile Identifier
MSH-21.1	Entity Identifier	Z23
MSH-21.2	Namespace ID	CDCPHINVS
MSH-21.3	Universal ID
MSH-21.4	Universal ID Type
MSH-22	Sending Responsible Organization
MSH-22.1	Organization Name	NISTIISFAC
MSH-22.6	Assigning Authority
MSH-22.7	Identifier Type Code
MSH-22.10	Organization Identifier
MSH-23	Receiving Responsible Organization
MSH-23.1	Organization Name	NISTEHRFAC
MSH-23.6	Assigning Authority
MSH-23.7	Identifier Type Code
MSH-23.10	Organization Identifier

MSA : Message Acknowledgment

Location	Data Element	Data	Categorization
MSA-1	Acknowledgment Code	AE
MSA-2	Message Control ID	NIST-IZ-AD-9.1_Send_V04_Z22

ERR[*]

ERR : Error

Location	Data Element	Data
ERR-2	Error Location
ERR-2.1	Segment ID	RXR
ERR-2.2	Segment Sequence	1
ERR-2.3	Field Position	2
ERR-2.4	Field Repetition	1
ERR-2.5	Component Number	1
ERR-2.6	Sub-Component Number
ERR-3	HL7 Error Code
ERR-3.1	Identifier	999
ERR-3.2	Text	Application error
ERR-3.3	Name of Coding System	HL70357
ERR-4	Severity	W
ERR-5	Application Error Code
ERR-5.1	Identifier	5
ERR-5.2	Text	Table value not found
ERR-5.3	Name of Coding System	HL70533
ERR-8	User Message	Administration Site not recognized - site data will not be saved

ERR : Error

Location	Data Element	Data
ERR-2	Error Location
ERR-2.1	Segment ID	RXR
ERR-2.2	Segment Sequence	2
ERR-2.3	Field Position	2
ERR-2.4	Field Repetition	1
ERR-2.5	Component Number	1
ERR-2.6	Sub-Component Number
ERR-3	HL7 Error Code
ERR-3.1	Identifier	999
ERR-3.2	Text	Application error
ERR-3.3	Name of Coding System	HL70357
ERR-4	Severity	W
ERR-5	Application Error Code
ERR-5.1	Identifier	5
ERR-5.2	Text	Table value not found
ERR-5.3	Name of Coding System	HL70533
ERR-8	User Message	Administration Site not recognized - site data will not be saved

Test Data Specification

Patient Information

Element	Data
This information will be automatically supplied by the System

6. Cohort Report

This test will consist of generating a cohort report to list all patients who are due or overdue for immunizations showing all overdue immunizations with the associated due/overdue dates.

Test Story

Description

Comments

Pre-condition

Post-Condition

Test Objectives

Evaluation Criteria

Notes

6.1. Due and Overdue Immunizations

List all patients who are due or overdue for immunizations showing all overdue immunizations.

Test Story

Description
The provider periodically uses the EMR to identify the cohort of patients that are due or overdue for immunizations along with their contact information in order to send reminder notifications to the patients/parents.

Comments
No Comments

Pre-condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. The vaccine forecast is available to the EMR.

Post-Condition
The Cohort report for all patients that are due or overdue for immunizations is available to the provider through the EMR.

Test Objectives
Produce Population-Level Report: The EHR or other clinical system generates aggregate, population-level reports based on known patient immunization data.

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
No Note

6.1.1. Produce Overdue Immunizations Cohort Report

Test Step Type: SUT_MANUAL
The provider uses the EMR to create a report for all patient vaccinations overdue with the contact information.

Test Story

Description
The provider periodically uses the EMR to identify the cohort of patients that are due or overdue for immunizations along with their contact information in order to send reminder notifications to the patients/parents.

Comments
No Comments

Pre-condition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. The vaccine forecast is available to the EMR.

Post-Condition
The Cohort report for all patients that are due or overdue for immunizations is available to the provider through the EMR.

Test Objectives
Produce Population-Level Report: The EHR or other clinical system generates aggregate, population-level reports based on known patient immunization data.

Evaluation Criteria

The following patient information is provided on the cohort report:

Patient Name	Juana Mariana Vazquez
Preferred Contact Method	Phone
Contact information using preferred contact (email, text, phone, mailing address)	(203) 555-1212
Patient Identifier Number	Vendor Supplied
Patient Identifier Type Code	Vendor Supplied
Date/Time of Birth	11/1/2013 11:05am
Sex	Female
Vaccine Group	IPV
Due Date	10/31/2017
Overdue Date	10/31/2019
Dose #	4
Dose in Series	4
Link to full record	Vendor Supplied

Patient Name	Juan Marcel Marina
Preferred Contact Method	Text
Contact information using preferred contact (email, text, phone, mailing address)	(203)555-1213
Patient Identifier Number	Vendor Supplied
Patient Identifier Type Code	Vendor Supplied
Date/Time of Birth	03/04/2017 1100a
Sex	Male
Vaccine Group	HepB
Due Date	08/31/2017
Overdue Date	09/01/2018
Dose #	3
Dose in Series	3
Link to full record	Vendor Supplied

Patient Name	Juana Mariela Gonzales
Preferred Contact Method	Text
Contact information using preferred contact (email, text, phone, mailing address)	(203) 555-1214
Patient Identifier Number	Vendor Supplied
Patient Identifier Type Code	Vendor Supplied
Date/Time of Birth	10/1/2018 11am
Sex	Female
Vaccine Group	Hep B Peds NOS
Due Date	10/31/2018
Overdue Date	12/1/2018
Dose #	2
Dose in Series	3
Vaccine Group	DTaP
Due Date	11/30/2018
Dose #	1
Dose in Series	5
Vaccine Group	Hib
Due Date	11/30/2018
Dose #	1
Dose in Series	4
Vaccine Group	IPV
Due Date	11/30/2018
Dose #	1
Dose in Series	4
Vaccine Group	Pneumococcal conjugate
Due Date	11/30/2018
Dose #	1
Dose in Series	4


Link to full record	Vendor Supplied

Patient Name	Juana Maria Gonzales
Preferred Contact Method	Text
Contact information using preferred contact (email, text, phone, mailing address)	(203) 555-1214
Patient Identifier Number	Vendor Supplied
Patient Identifier Type Code	Vendor Supplied
Date/Time of Birth	10/1/2018 11:15am
Sex	Female
Vaccine Group	Hib
Due Date	11/30/2018
Dose #	1
Dose in Series	4
Vaccine Group	Pneumococcal conjugate
Due Date	11/30/2018
Dose #	1
Dose in Series	4


Link to full record	Vendor Supplied

Notes
No Note

7. Review Inventory

Demonstrates the ability to view inventory supply, including deprecated inventory used.

Test Story

Description

Comments

Pre-condition

Post-Condition

Test Objectives

Evaluation Criteria

Notes

7.1. View Inventory

Demonstrates the ability to view updated inventory supply.

Test Story

Description
The provider reviews the available inventory following vaccine administrations used during the day.

Comments
No Comments

Pre-condition
Vaccine inventory entered. Vaccines administered for Juana Mariana Vazquez, Juan Marcel Marina, and Juana Maria Gonzales.

Post-Condition
Available vaccine inventory displayed.

Test Objectives
Update Vaccine Inventory from Patient Dosage Administration: The system updates the vaccine inventory to assure the correct count of remaining available vaccine inventory.

Evaluation Criteria
Evaluation criteria is defined within each test step.

Notes
This test step is introduced in 2018 and will be considered an evaluation year for the test step. Tester should document feedback and issues.

7.1.1. View updated vaccine inventory

Test Step Type: SUT_MANUAL
Demonstrates the ability to view updated inventory supply.

Test Story

Description
The provider reviews the available inventory following vaccine administrations used during the day.

Comments
No Comments

Pre-condition
Vaccine inventory entered. Vaccines administered for Juana Mariana Vazquez, Juan Marcel Marina, and Juana Maria Gonzales.

Post-Condition
Available vaccine inventory displayed.

Test Objectives
Update Vaccine Inventory from Patient Dosage Administration: The system updates the vaccine inventory to assure the correct count of remaining available vaccine inventory.

Evaluation Criteria

The EMR inventory shows (minimally):

1. Manufacturer: Novartis Vaccines and Diagnostics Ltd

NDC:66521-0113-02

Product Name:FLUVIRIN

Lot#:8L4B3521

Expiration Date:12/31/2019

Vaccine source:VFC

Quantity:24 Syringes (or doses)

2. Manufacturer: Sanofi Pasteur Inc.

NDC:49281-0413-58

Product Name:FLUZONE QUADRIVALENT